1497837421 NPI number — ROGER VINES LLC

Table of content: MR. AARON M. SMITH PTA (NPI 1538687157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497837421 NPI number — ROGER VINES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROGER VINES 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:
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:
1497837421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 B ST
Provider Second Line Business Mailing Address:
P.O. BOX 198
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36862-2095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-864-7128
Provider Business Mailing Address Fax Number:
334-864-8184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 B ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36862-2095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-864-7128
Provider Business Practice Location Address Fax Number:
334-864-8184
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VINES LLC
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
334-864-7128

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  411 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 051052949 . This is a "BC/BS OF ALABAMA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 104579 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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