1497837421 NPI number — ROGER VINES LLC

Table of content: (NPI 1497837421)

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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