MEDICARE: BLACK VINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	348111	MN

General Provider Information

NPI Number	:	1326359159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK VINE LLC

Provider Business Mailing Address
First Line	:	4445 W 77TH ST
Second Line	:	SUITE 122
City	:	EDINA
State	:	MN
Zip	:	55435-5133
Country	:	US
Telephone Number	:	952-960-2266
Fax Number	:	952-960-2267

Provider Business Practice Location Address
First Line	:	4445 W 77TH ST
Second Line	:	SUITE 122
City	:	EDINA
State	:	MN
Zip	:	55435-5133
Country	:	US
Telephone Number	:	952-960-2266
Fax Number	:	952-960-2267

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SAM A MITCHELL
Credential	:
Telephone Number	:	952-960-2266

Provider Enumeration Date	:	06/25/2010
Last Update Date	:	06/25/2010

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Directions to “BLACK VINE LLC ” Practice Location

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