Provider Demographics
NPI:1447915459
Name:TENNYSON, VINCENT J
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:J
Last Name:TENNYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10647 OLD INDIAN TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-7419
Mailing Address - Country:US
Mailing Address - Phone:817-891-2346
Mailing Address - Fax:
Practice Address - Street 1:413 HIGHWAY 70 N
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-8235
Practice Address - Country:US
Practice Address - Phone:580-564-7308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator