MEDICARE: MR. JARVIN VINES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	FL
2	320700000X	Physical Disabilities Residential Treatment Facility
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164950929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JARVIN VINES

Provider Business Mailing Address
First Line	:	7215 JONQUIL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-5808
Country	:	US
Telephone Number	:	407-305-1925
Fax Number	:

Provider Business Practice Location Address
First Line	:	7215 JONQUIL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-5808
Country	:	US
Telephone Number	:	407-305-1925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2017
Last Update Date	:	07/22/2024

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Directions to “ MR. JARVIN VINES ” Practice Location

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