Provider Demographics
NPI:1376057398
Name:VINE GATE INC.
Entity Type:Organization
Organization Name:VINE GATE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FUNKE
Authorized Official - Middle Name:CINDERELA
Authorized Official - Last Name:AJIBOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-497-6791
Mailing Address - Street 1:85 HOLLAND AVENUE
Mailing Address - Street 2:APT 12L
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303
Mailing Address - Country:US
Mailing Address - Phone:917-497-6791
Mailing Address - Fax:
Practice Address - Street 1:42 AMITY PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303
Practice Address - Country:US
Practice Address - Phone:917-497-6791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty