Provider Demographics
NPI:1174679625
Name:VINELCO PHYSICIANS ASSOCIATES LLC
Entity Type:Organization
Organization Name:VINELCO PHYSICIANS ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-798-2399
Mailing Address - Street 1:PO BOX 53032
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-3032
Mailing Address - Country:US
Mailing Address - Phone:318-932-2081
Mailing Address - Fax:318-932-2215
Practice Address - Street 1:4900 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4521
Practice Address - Country:US
Practice Address - Phone:318-932-2081
Practice Address - Fax:318-932-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11956R282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1315290Medicaid
LADQ1007OtherRR MEDICARE GROUP NUMBER
LA5CV98Medicare PIN