Healthcare Provider Details

I. General information

NPI: 1356625966
Provider Name (Legal Business Name): VINE STREET CLINICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 HEDLEY RD
SPRINGFIELD IL
62711-6248
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-726-7300
  • Fax:
Mailing address:
  • Phone: 800-577-5368
  • Fax: 217-757-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: J TRAVIS DOWELL
Title or Position: VICE PRESIDENT MPS AND OPERATIONS
Credential:
Phone: 217-788-3342