=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255038477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VINTAGE PSYCHIATRIC CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2023
-----------------------------------------------------
Last Update Date | 08/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7163 HIAWASSEE OAK DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-8357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-237-0399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7163 HIAWASSEE OAK DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32818-8357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-237-0399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | VADA PARKE-GASKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-237-0399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------