1124384524 NPI number — VINCE C. IRENE, DC., PLLC

Table of content: (NPI 1124384524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124384524 NPI number — VINCE C. IRENE, DC., PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINCE C. IRENE, DC., PLLC
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:
6
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:
1124384524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8135 HIGHWAY 789
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANDER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82520-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-332-4200
Provider Business Mailing Address Fax Number:
307-332-3133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8135 HIGHWAY 789
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANDER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82520-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-332-4200
Provider Business Practice Location Address Fax Number:
307-332-3133
Provider Enumeration Date:
04/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
IRENE
Authorized Official First Name:
VINCE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC
Authorized Official Telephone Number:
307-332-4200

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  532 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114702100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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