Healthcare Provider Details

I. General information

NPI: 1588393110
Provider Name (Legal Business Name): MARCY'S VANTAGE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S EAST ST
PONCA NE
68770-7264
US

IV. Provider business mailing address

PO BOX 645
PONCA NE
68770-0645
US

V. Phone/Fax

Practice location:
  • Phone: 712-251-7523
  • Fax: 402-755-2387
Mailing address:
  • Phone: 712-251-7523
  • Fax: 402-755-2387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: MARCY ROSE JOHNSON
Title or Position: OWNER
Credential:
Phone: 712-251-7523