Provider Demographics
NPI:1982648267
Name:VAMANA INC
Entity Type:Organization
Organization Name:VAMANA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING / BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TIMICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-773-1111
Mailing Address - Street 1:422 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5310
Mailing Address - Country:US
Mailing Address - Phone:870-773-1111
Mailing Address - Fax:870-772-7692
Practice Address - Street 1:422 BEECH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5310
Practice Address - Country:US
Practice Address - Phone:870-773-1111
Practice Address - Fax:870-772-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) TreatmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166879134Medicaid