Provider Demographics
NPI:1568157667
Name:INGLE, VANCE BAXTER
Entity Type:Individual
Prefix:MR
First Name:VANCE
Middle Name:BAXTER
Last Name:INGLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 VALLEY LAKE TRL
Mailing Address - Street 2:
Mailing Address - City:MINERAL BLUFF
Mailing Address - State:GA
Mailing Address - Zip Code:30559-2643
Mailing Address - Country:US
Mailing Address - Phone:706-455-8619
Mailing Address - Fax:
Practice Address - Street 1:442 VALLEY LAKE TRL
Practice Address - Street 2:
Practice Address - City:MINERAL BLUFF
Practice Address - State:GA
Practice Address - Zip Code:30559-2643
Practice Address - Country:US
Practice Address - Phone:706-455-8619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty