MEDICARE: VINTAGE PARK AT HIAWATHA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194973321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINTAGE PARK AT HIAWATHA, LLC

Provider Business Mailing Address
First Line	:	400 KANSAS AVE
Second Line	:
City	:	HIAWATHA
State	:	KS
Zip	:	66434-1954
Country	:	US
Telephone Number	:	785-742-4566
Fax Number	:	785-742-4573

Provider Business Practice Location Address
First Line	:	400 KANSAS AVE
Second Line	:
City	:	HIAWATHA
State	:	KS
Zip	:	66434-1954
Country	:	US
Telephone Number	:	785-742-4566
Fax Number	:	785-742-4573

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MATT MOORE
Credential	:
Telephone Number	:	949-282-5800

Provider Enumeration Date	:	08/29/2008
Last Update Date	:	08/29/2008

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