=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811154412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINNIE VANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2008
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2507 MCCALLIE AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37404-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-624-8226
-----------------------------------------------------
Fax | 423-624-2246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2507 MCCALLIE AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37404-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-624-8226
-----------------------------------------------------
Fax | 423-624-2246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER,OPERATOR
-----------------------------------------------------
Name | DR. MINNIE RATLIFF VANCE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 423-624-8226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD1768
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------