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General NPI Number Information
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NPI Number | 1407427420
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Entity Type | Organization
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Legal Business Name | VINE FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 07/09/2021
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Last Update Date | 07/12/2021
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Provider Practice Location Address
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Address Line | 420 JOHNSON RD STE 304
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City | KELLER
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State | TX
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Zip | 76248-3463
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Country | US
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Telephone | 817-710-3040
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Fax | 989-200-4650
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Provider Business Mailing Address
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Address Line | 420 JOHNSON RD STE 304
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City | KELLER
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State | TX
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Zip | 76248-3463
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Country | US
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Telephone | 817-710-3040
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Fax | 989-200-4650
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. OCHUELE ODUMOSU
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Credential | MD
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Telephone | 817-710-3040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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