=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841525672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANTAGE PLACE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2009
-----------------------------------------------------
Last Update Date | 02/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3105 FRANKLIN BLVD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44113-2946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-566-8707
-----------------------------------------------------
Fax | 216-566-8329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5579 PEARL RD STE 200
-----------------------------------------------------
City | PARMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44129-2555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-885-0100
-----------------------------------------------------
Fax | 440-885-0221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. BOB ROYER
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 216-566-8707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | 5577
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------