Provider Demographics
NPI:1124561907
Name:VAHLE, ERIC
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:VAHLE
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 1:3611 WAKEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4462
Mailing Address - Country:US
Mailing Address - Phone:573-881-9624
Mailing Address - Fax:
Practice Address - Street 1:3611 WAKEFIELD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4462
Practice Address - Country:US
Practice Address - Phone:573-881-9624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities