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General NPI Number Information
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NPI Number | 1275894875
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Entity Type | Organization
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Legal Business Name | VINEYARD PERSONALIZED MEDICINE LLC
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Dates
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Enumeration Date | 05/31/2012
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Last Update Date | 11/25/2015
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Provider Practice Location Address
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Address Line | 24 COURNOYER RD
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City | WEST TISBURY
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State | MA
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Zip | 02575
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Country | US
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Telephone | 508-693-1300
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Fax | 508-693-1305
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Provider Business Mailing Address
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Address Line | 24 COURNOYER RD
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City | VINEYARD HAVEN
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State | MA
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Zip | 02568-7625
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Country | US
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Telephone | 508-693-1300
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Fax | 508-693-1305
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | LISA NAGY
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Credential | MD
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Telephone | 508-693-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 72590
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License Number State | MA
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