Basic Information
| Provider Information | |||||||||
| NPI: | 1174679625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VINELCO PHYSICIANS ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53032 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711353032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189322081 | ||||||||
| FaxNumber: | 3189322215 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711124521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189322081 | ||||||||
| FaxNumber: | 3189322215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 09/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHICO | ||||||||
| AuthorizedOfficialFirstName: | GAVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3187982399 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 11956R | LA | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1315290 | 05 | LA | MEDICAID | DQ1007 | 01 | LA | RR MEDICARE GROUP NUMBER | OTHER |