MEDICARE: VINTAGE SPECIALIZED SERVICES 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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1366002073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINTAGE SPECIALIZED SERVICES LLC

Provider Business Mailing Address
First Line	:	207 E BELLEVUE ST
Second Line	:
City	:	LESLIE
State	:	MI
Zip	:	49251-9373
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2055 PERRINE RD
Second Line	:
City	:	RIVES JUNCTION
State	:	MI
Zip	:	49277-9735
Country	:	US
Telephone Number	:	517-574-2401
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LATOSHIA LYNN BARUTI
Credential	:
Telephone Number	:	517-574-2401

Provider Enumeration Date	:	06/14/2019
Last Update Date	:	06/14/2019

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Directions to “VINTAGE SPECIALIZED SERVICES LLC ” Practice Location

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