Healthcare Provider Details

I. General information

NPI: 1770942526
Provider Name (Legal Business Name): MRS. MARY VINESKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 GRAND AVE
STAFFORD KS
67578-2009
US

IV. Provider business mailing address

405 GRAND AVE
STAFFORD KS
67578
US

V. Phone/Fax

Practice location:
  • Phone: 620-234-5208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: