Healthcare Provider Details

I. General information

NPI: 1912373101
Provider Name (Legal Business Name): JESSIE VANCE RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 RAVINE RD
ASHEVILLE NC
28804-3220
US

IV. Provider business mailing address

2 RAVINE RD
ASHEVILLE NC
28804-3220
US

V. Phone/Fax

Practice location:
  • Phone: 828-708-0612
  • Fax:
Mailing address:
  • Phone: 828-708-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279E0002X
TaxonomyEmergency Care Registered Respiratory Therapist
License Number4660-28
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: