Healthcare Provider Details

I. General information

NPI: 1376057398
Provider Name (Legal Business Name): VINE GATE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 AMITY PL
STATEN ISLAND NY
10303
US

IV. Provider business mailing address

85 HOLLAND AVENUE APT 12L
STATEN ISLAND NY
10303
US

V. Phone/Fax

Practice location:
  • Phone: 917-497-6791
  • Fax:
Mailing address:
  • Phone: 917-497-6791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. FUNKE CINDERELA AJIBOYE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 917-497-6791