1740312826 NPI number — GRETA MARLA VINES-DOUGLAS PA-C

Table of content: GRETA MARLA VINES-DOUGLAS PA-C (NPI 1740312826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740312826 NPI number — GRETA MARLA VINES-DOUGLAS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VINES-DOUGLAS
Provider First Name:
GRETA
Provider Middle Name:
MARLA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VINES
Provider Other First Name:
GRETA
Provider Other Middle Name:
MARLA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740312826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5823 YORK BLVD # 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90042-2634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-255-5643
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 WASHINGTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEBELLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90640-6123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-728-3955
Provider Business Practice Location Address Fax Number:
323-728-6905
Provider Enumeration Date:
03/12/2007

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: 363A00000X , with the licence number:  PA13987 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00381919 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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