Provider Demographics
NPI:1528456696
Name:VACCA PHYSIATRY LLC
Entity type:Organization
Organization Name:VACCA PHYSIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:VACCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-622-1300
Mailing Address - Street 1:10928 EAGLE RIVER RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8078
Mailing Address - Country:US
Mailing Address - Phone:907-622-1300
Mailing Address - Fax:
Practice Address - Street 1:10928 EAGLE RIVER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8078
Practice Address - Country:US
Practice Address - Phone:907-622-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51455208100000X
AK103783261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty