Provider Demographics
NPI:1811154412
Name:MINNIE VANCE
Entity type:Organization
Organization Name:MINNIE VANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MINNIE
Authorized Official - Middle Name:RATLIFF
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-624-8226
Mailing Address - Street 1:2507 MCCALLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3304
Mailing Address - Country:US
Mailing Address - Phone:423-624-8226
Mailing Address - Fax:423-624-2246
Practice Address - Street 1:2507 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3304
Practice Address - Country:US
Practice Address - Phone:423-624-8226
Practice Address - Fax:423-624-2246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD1768174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA97559Medicare UPIN