Healthcare Provider Details

I. General information

NPI: 1104648757
Provider Name (Legal Business Name): VINTAGE COURT HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620-B DALE RD
MODESTO CA
95356-0598
US

IV. Provider business mailing address

3620 DALE RD
MODESTO CA
95356-0598
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-2094
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: SECRETARY
Credential:
Phone: 949-540-1249