Provider Demographics
NPI:1093763732
Name:VANDERPOOL, TONY WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:WAYNE
Last Name:VANDERPOOL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:ANTHONY
Other - Middle Name:WAYNE
Other - Last Name:VANDERPOOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1965 RIVIERA DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7469
Mailing Address - Country:US
Mailing Address - Phone:843-884-7100
Mailing Address - Fax:843-884-7340
Practice Address - Street 1:1965 RIVIERA DR
Practice Address - Street 2:SUITE 3
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7469
Practice Address - Country:US
Practice Address - Phone:843-884-7100
Practice Address - Fax:843-884-7340
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2149111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2149Medicaid
SCCH2149Medicaid
SCU586180281Medicare ID - Type UnspecifiedMEDICARE ID