Provider Demographics
NPI:1679687180
Name:VINES, ROSS R (PT)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:R
Last Name:VINES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE G-10
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1646
Mailing Address - Country:US
Mailing Address - Phone:512-345-5925
Mailing Address - Fax:512-343-7113
Practice Address - Street 1:3724 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE G-10
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1646
Practice Address - Country:US
Practice Address - Phone:512-345-5925
Practice Address - Fax:512-343-7113
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1038339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2428Medicare ID - Type UnspecifiedMEDICARE