Provider Demographics
NPI:1982468542
Name:VANDRUNEN, MIKIO JAMES
Entity type:Individual
Prefix:
First Name:MIKIO
Middle Name:JAMES
Last Name:VANDRUNEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15728 LORAIN AVE STE 47
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-5542
Mailing Address - Country:US
Mailing Address - Phone:513-331-3564
Mailing Address - Fax:
Practice Address - Street 1:17325 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1247
Practice Address - Country:US
Practice Address - Phone:513-331-3564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator