Healthcare Provider Details

I. General information

NPI: 1386974582
Provider Name (Legal Business Name): DEIRDRE'S VINTAGE HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27277 BAGLEY RD
OLMSTED FALLS OH
44138-1001
US

IV. Provider business mailing address

27277 BAGLEY RD
OLMSTED FALLS OH
44138-1001
US

V. Phone/Fax

Practice location:
  • Phone: 440-476-8905
  • Fax: 440-793-6359
Mailing address:
  • Phone: 440-476-8905
  • Fax: 440-793-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number3270AGH
License Number StateOH

VIII. Authorized Official

Name: MRS. DEIRDRE FAITH NEWMAN
Title or Position: OWNER/MANAGER
Credential: L.P.N.
Phone: 440-476-8905