Provider Demographics
NPI:1548882426
Name:VINE MEDICAL SERVICES
Entity type:Organization
Organization Name:VINE MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELIJAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NYASENDE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:214-208-5829
Mailing Address - Street 1:5409 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-8384
Mailing Address - Country:US
Mailing Address - Phone:214-208-5829
Mailing Address - Fax:
Practice Address - Street 1:5409 PINEWOOD DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-8384
Practice Address - Country:US
Practice Address - Phone:214-208-5829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1760891568OtherNPPES