Healthcare Provider Details

I. General information

NPI: 1124561907
Provider Name (Legal Business Name): MR. ERIC VAHLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 WAKEFIELD DR
COLUMBIA MO
65203-4462
US

IV. Provider business mailing address

3611 WAKEFIELD DR
COLUMBIA MO
65203-4462
US

V. Phone/Fax

Practice location:
  • Phone: 573-881-9624
  • Fax:
Mailing address:
  • Phone: 573-881-9624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: