| Vine Family Medicine Pllc | |
|
420 Johnson Rd Ste 304 Keller TX 76248-3463 | |
| (817) 710-3040 | |
| (989) 200-4650 |
| Full Name | Vine Family Medicine Pllc |
|---|---|
| Speciality | Family Medicine |
| Location | 420 Johnson Rd Ste 304, Keller, Texas |
| Authorized Official Name and Position | Ochuele Odumosu (MEDICAL DIRECTOR) |
| Authorized Official Contact | 8177103040 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Vine Family Medicine Pllc 420 Johnson Rd Ste 304 Keller TX 76248-3463 Ph: (817) 710-3040 | Vine Family Medicine Pllc 420 Johnson Rd Ste 304 Keller TX 76248-3463 Ph: (817) 710-3040 |
| NPI Number | 1407427420 |
|---|---|
| Provider Enumeration Date | 07/09/2021 |
| Last Update Date | 07/12/2021 |
| Medicare PECOS PAC ID | 9537563416 |
|---|---|
| Medicare Enrollment ID | O20210816000324 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407427420 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Oluwaseun O Odumosu |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1356654909 PECOS PAC ID: 3678797453 Enrollment ID: I20190719001608 |
| Provider Name | Ochuele Odumosu |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1891079323 PECOS PAC ID: 5991923872 Enrollment ID: I20210816000426 |
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