Healthcare Provider Details

I. General information

NPI: 1376598763
Provider Name (Legal Business Name): VINTAGE CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 NEWBURG RD
LOUISVILLE KY
40205-1803
US

IV. Provider business mailing address

PO BOX 436196
LOUISVILLE KY
40253-6196
US

V. Phone/Fax

Practice location:
  • Phone: 502-883-6744
  • Fax: 502-883-6743
Mailing address:
  • Phone: 502-883-6744
  • Fax: 502-883-6743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BONNIE A LAZOR
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 502-883-6744