Healthcare Provider Details

I. General information

NPI: 1255643698
Provider Name (Legal Business Name): VINTAGE PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 E 12TH AVE
EL DORADO KS
67042-4300
US

IV. Provider business mailing address

1650 E 12TH AVE
EL DORADO KS
67042-4300
US

V. Phone/Fax

Practice location:
  • Phone: 316-321-7777
  • Fax: 316-321-6115
Mailing address:
  • Phone: 316-321-7777
  • Fax: 316-321-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberN008009
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberN008009
License Number StateKS

VIII. Authorized Official

Name: MR. BRIAN WARREN
Title or Position: OWNER
Credential:
Phone: 316-733-1144