Healthcare Provider Details

I. General information

NPI: 1740312826
Provider Name (Legal Business Name): GRETA MARLA VINES-DOUGLAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETA MARLA VINES PA-C

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 WASHINGTON BLVD
MONTEBELLO CA
90640-6123
US

IV. Provider business mailing address

5823 YORK BLVD # 3
LOS ANGELES CA
90042-2634
US

V. Phone/Fax

Practice location:
  • Phone: 323-728-3955
  • Fax: 323-728-6905
Mailing address:
  • Phone: 323-255-5643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13987
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: