Healthcare Provider Details

I. General information

NPI: 1669529566
Provider Name (Legal Business Name): MR. IRWIN R VANDYGRIFF I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 WOODELL ST
CLINTON AR
72031-6929
US

IV. Provider business mailing address

179 WOODELL ST
CLINTON AR
72031-6929
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-4060
  • Fax: 501-745-4012
Mailing address:
  • Phone: 501-745-4060
  • Fax: 501-745-4012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: