Healthcare Provider Details

I. General information

NPI: 1033109491
Provider Name (Legal Business Name): KEVIN RICK VANDERHOEF OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 BIG A RD
TOCCOA GA
30577-6010
US

IV. Provider business mailing address

1020 BIG A RD
TOCCOA GA
30577-6010
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-0111
  • Fax: 706-886-7680
Mailing address:
  • Phone: 706-886-0111
  • Fax: 706-886-7680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT001577
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000743003D
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: