Healthcare Provider Details

I. General information

NPI: 1871039479
Provider Name (Legal Business Name): VINTAGE VINETOURS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14361 HWY 128 BOX 236
BOONVILLE CA
95415
US

IV. Provider business mailing address

14361 HWY 128 BOX 236
BOONVILLE CA
95415
US

V. Phone/Fax

Practice location:
  • Phone: 707-895-2641
  • Fax:
Mailing address:
  • Phone: 707-895-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberC6528142
License Number StateCA

VIII. Authorized Official

Name: MR. WILLIAM RAY HOUSLEY
Title or Position: GENERAL MANAGER
Credential:
Phone: 707-485-4879