Provider Demographics
NPI:1851071898
Name:FORTIETH & VINEYARD COMPANY LLC
Entity Type:Organization
Organization Name:FORTIETH & VINEYARD COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROSTHESIS SPECIALISTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:PEGUES
Authorized Official - Suffix:
Authorized Official - Credentials:SPECIALIST
Authorized Official - Phone:314-496-0178
Mailing Address - Street 1:2369 WESFORD DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-4147
Mailing Address - Country:US
Mailing Address - Phone:314-496-0178
Mailing Address - Fax:
Practice Address - Street 1:10781 NORTH OUTER 40 ROAD
Practice Address - Street 2:117
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005
Practice Address - Country:US
Practice Address - Phone:314-496-0178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty