1326025784 NPI number — MR. MACK EVANS HADDOCK CRNA

Table of content: MR. MACK EVANS HADDOCK CRNA (NPI 1326025784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326025784 NPI number — MR. MACK EVANS HADDOCK CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HADDOCK
Provider First Name:
MACK
Provider Middle Name:
EVANS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326025784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 SOLEDAD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THE VILLAGES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32159-9112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-259-7483
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1160 SE 18TH PL
Provider Second Line Business Practice Location Address:
OCALA ENDOSCOPY CENTER
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471-5422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-732-8905
Provider Business Practice Location Address Fax Number:
352-732-2440
Provider Enumeration Date:
12/28/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  9201655 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)