1154569507 NPI number — VINONAGROUPSERVICESUSA,LLC

Table of content: (NPI 1154569507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154569507 NPI number — VINONAGROUPSERVICESUSA,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINONAGROUPSERVICESUSA,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1154569507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 MANOMET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROCKTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02301-5024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-584-4499
Provider Business Mailing Address Fax Number:
508-587-8338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 MANOMET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-5024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-584-4499
Provider Business Practice Location Address Fax Number:
508-587-8338
Provider Enumeration Date:
01/22/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ANDY
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER & CEO
Authorized Official Telephone Number:
508-584-4499

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WA0400X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WC0400X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WH0200X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164W00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372500000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372600000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747A0650X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747P1801X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 376J00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 376K00000X , with the licence number: 436587588A , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 376K00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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