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NPI Code Detail

MEDICARE: GRETA MARLA VINES-DOUGLAS PA-C

MEDICARE: GRETA MARLA VINES-DOUGLAS PA-C
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA13987CA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P00381919OTHERGAMEDICARE RAILROAD

General Provider Information

NPI Number : 1740312826
Entity Type Code : Individual
Provider Name (Legal Business Name) : GRETA MARLA VINES-DOUGLAS PA-C
Provider Business Mailing Address
First Line : 5823 YORK BLVD # 3
Second Line :
City : LOS ANGELES
State : CA
Zip : 90042-2634
Country : US
Telephone Number : 323-255-5643
Fax Number :
Provider Business Practice Location Address
First Line : 815 WASHINGTON BLVD
Second Line :
City : MONTEBELLO
State : CA
Zip : 90640-6123
Country : US
Telephone Number : 323-728-3955
Fax Number : 323-728-6905
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/12/2007
Last Update Date : 01/11/2018

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Directions to “ GRETA MARLA VINES-DOUGLAS PA-C” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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