Provider Demographics
NPI:1043926835
Name:CORE VINE FAMILY SRV LLC
Entity type:Organization
Organization Name:CORE VINE FAMILY SRV LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAWANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-473-0148
Mailing Address - Street 1:701 E WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-2425
Mailing Address - Country:US
Mailing Address - Phone:602-487-8331
Mailing Address - Fax:
Practice Address - Street 1:701 E WESTERN AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-2425
Practice Address - Country:US
Practice Address - Phone:602-487-8331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health