Provider Demographics
NPI:1184165169
Name:ALEXANDER, VINCENT & ALEXANDRIA LLC
Entity type:Organization
Organization Name:ALEXANDER, VINCENT & ALEXANDRIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CLAYBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-299-7236
Mailing Address - Street 1:4795 MCWILLIE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5628
Mailing Address - Country:US
Mailing Address - Phone:769-524-4191
Mailing Address - Fax:769-524-4208
Practice Address - Street 1:219 FORD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-3322
Practice Address - Country:US
Practice Address - Phone:662-299-7236
Practice Address - Fax:769-524-4208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09603294251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09603294Medicaid