Healthcare Provider Details

I. General information

NPI: 1043149727
Provider Name (Legal Business Name): VINTAGE ROOTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S COUNTY ROAD 475 E
SELMA IN
47383-9679
US

IV. Provider business mailing address

5401 S COUNTY ROAD 475 E
SELMA IN
47383-9679
US

V. Phone/Fax

Practice location:
  • Phone: 765-748-3775
  • Fax:
Mailing address:
  • Phone: 765-748-3775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY TURNER
Title or Position: OWNER
Credential: RN
Phone: 765-748-3775