Provider Demographics
NPI:1225708506
Name:BRANCHES OF THE VINE
Entity Type:Organization
Organization Name:BRANCHES OF THE VINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:605-850-1532
Mailing Address - Street 1:19415 US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:LEMMON
Mailing Address - State:SD
Mailing Address - Zip Code:57638-6303
Mailing Address - Country:US
Mailing Address - Phone:605-850-1532
Mailing Address - Fax:
Practice Address - Street 1:204 SOUTH 4TH AVE WEST
Practice Address - Street 2:
Practice Address - City:FAITH
Practice Address - State:SD
Practice Address - Zip Code:57626
Practice Address - Country:US
Practice Address - Phone:605-850-1532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty