Healthcare Provider Details

I. General information

NPI: 1366002073
Provider Name (Legal Business Name): VINTAGE SPECIALIZED SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 PERRINE RD
RIVES JUNCTION MI
49277-9735
US

IV. Provider business mailing address

207 E BELLEVUE ST
LESLIE MI
49251-9373
US

V. Phone/Fax

Practice location:
  • Phone: 517-574-2401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LATOSHIA LYNN BARUTI
Title or Position: ADMINISTRATOR
Credential:
Phone: 517-574-2401