Provider Demographics
NPI:1497837421
Name:ROGER VINES LLC
Entity Type:Organization
Organization Name:ROGER VINES LLC
Other - Org Name:VINES AMBULANCE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:VINES LLC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-864-7128
Mailing Address - Street 1:211 B ST
Mailing Address - Street 2:P.O. BOX 198
Mailing Address - City:LAFAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36862-2095
Mailing Address - Country:US
Mailing Address - Phone:334-864-7128
Mailing Address - Fax:334-864-8184
Practice Address - Street 1:211 B ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:AL
Practice Address - Zip Code:36862-2095
Practice Address - Country:US
Practice Address - Phone:334-864-7128
Practice Address - Fax:334-864-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2014-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4113416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051052949OtherBC/BS OF ALABAMA
AL104579Medicaid
AL510G590006Medicare PIN