Provider Demographics
NPI:1326359159
Name:BLACK VINE LLC
Entity Type:Organization
Organization Name:BLACK VINE LLC
Other - Org Name:COMFORCARE SENIOR SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-960-2266
Mailing Address - Street 1:4445 W 77TH ST
Mailing Address - Street 2:SUITE 122
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5133
Mailing Address - Country:US
Mailing Address - Phone:952-960-2266
Mailing Address - Fax:952-960-2267
Practice Address - Street 1:4445 W 77TH ST
Practice Address - Street 2:SUITE 122
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5133
Practice Address - Country:US
Practice Address - Phone:952-960-2266
Practice Address - Fax:952-960-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN348111251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management