Organization
VINE STREET CLINICAL ASSOCIATES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
J TRAVIS DOWELL (VICE PRESIDENT MPS AND OPERATIONS)
(217) 788-3342
Entity
Organization
Contact information
Practice address
3225 HEDLEY RD, SPRINGFIELD, IL 62711-6248
(217) 726-7300
Mailing address
PO BOX 3428, SPRINGFIELD, IL 62708-3428
(800) 577-5368
(217) 757-2021
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
—
—
364SP0809X
Adult Psychiatric/Mental Health Clinical Nurse Specialist
—
—
Other
Enumeration date
09/30/2011
Last updated
09/30/2011
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