Provider Demographics
NPI:1902841323
Name:VANTIEM, RENEE A (DC)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:A
Last Name:VANTIEM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 E 6TH ST STE B6
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-2371
Mailing Address - Country:US
Mailing Address - Phone:951-200-5066
Mailing Address - Fax:
Practice Address - Street 1:851 E 6TH ST STE B6
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-2371
Practice Address - Country:US
Practice Address - Phone:951-200-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001913A111N00000X
CADC 29267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 29267OtherASHP, BLUE CROSS
CADC 29267OtherASHP, BLUE CROSS
CAU80093Medicare UPIN