Healthcare Provider Details

I. General information

NPI: 1295087187
Provider Name (Legal Business Name): KEITH BARRINGTON VANDERPOOL BS RPSGT, RST, CSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 11/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR STE 3309701
LARGO MD
20774
US

IV. Provider business mailing address

9701 APOLLO DR STE 3309701
LARGO MD
20774-4783
US

V. Phone/Fax

Practice location:
  • Phone: 301-925-4510
  • Fax: 301-925-4510
Mailing address:
  • Phone: 301-925-4510
  • Fax: 301-925-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberZ0000042
License Number StateMD

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: