Healthcare Provider Details

I. General information

NPI: 1194723049
Provider Name (Legal Business Name): WILLIAM MAC VANDERPOOL JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 LAKE ALFRED RD
WINTER HAVEN FL
33881-1435
US

IV. Provider business mailing address

PO BOX 950
AUBURNDALE FL
33823-0950
US

V. Phone/Fax

Practice location:
  • Phone: 863-595-1440
  • Fax:
Mailing address:
  • Phone: 863-595-1440
  • Fax: 863-595-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1312052
License Number StateFL

VIII. Authorized Official

Name: MR. WILLIAM MAC VANDERPOOL JR.
Title or Position: OWNER
Credential:
Phone: 863-595-1440