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General NPI Number Information
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NPI Number | 1396185856
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Entity Type | Organization
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Legal Business Name | VINTAGE TIME LLC
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Dates
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Enumeration Date | 06/28/2013
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Last Update Date | 06/28/2013
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Provider Practice Location Address
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Address Line | 1448 HUMMINGBIRD LN
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-5443
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Country | US
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Telephone | 520-335-2001
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Fax | 520-335-2001
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Provider Business Mailing Address
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Address Line | 26 E KAYETAN DR
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-1116
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Country | US
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Telephone | 253-225-1474
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MRS. PRISCILLA C CULP
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Credential | RN MS
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Telephone | 253-225-1474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | AL7415H
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License Number State | AZ
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