Healthcare Provider Details

I. General information

NPI: 1053776294
Provider Name (Legal Business Name): VANTAGE GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 NORTH PLAINS HWY UNIT 15
WALLINGFORD CT
06492-5838
US

IV. Provider business mailing address

29 NORTH PLAINS HIGHWAY UNIT 15
WALLINGFORD CT
06492-5838
US

V. Phone/Fax

Practice location:
  • Phone: 203-234-7737
  • Fax:
Mailing address:
  • Phone: 203-234-7737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RICHARD PITTMAN
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, CSS
Phone: 203-234-7737