Provider Demographics
NPI:1730552340
Name:VINCENT, BRIAN
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:VINCENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11342 LANTANA REACH DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1476
Mailing Address - Country:US
Mailing Address - Phone:847-924-4101
Mailing Address - Fax:
Practice Address - Street 1:11342 LANTANA REACH DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-1476
Practice Address - Country:US
Practice Address - Phone:847-924-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILV52506183020172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver