Provider Demographics
NPI:1407427420
Name:VINE FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:VINE FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OCHUELE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUMOSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-710-3040
Mailing Address - Street 1:420 JOHNSON RD STE 304
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3463
Mailing Address - Country:US
Mailing Address - Phone:817-710-3040
Mailing Address - Fax:989-200-4650
Practice Address - Street 1:420 JOHNSON RD STE 304
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3463
Practice Address - Country:US
Practice Address - Phone:817-710-3040
Practice Address - Fax:989-200-4650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-09
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty