MEDICARE: VINTAGE PRIMARY CARE, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251J00000X	Nursing Care Agency
2	253Z00000X	In Home Supportive Care Agency
3	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1679036693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINTAGE PRIMARY CARE, PLLC

Provider Business Mailing Address
First Line	:	201 PRUITT RD APT 430
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77380-3167
Country	:	US
Telephone Number	:	973-640-0074
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 PRUITT RD APT 430
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77380-3167
Country	:	US
Telephone Number	:	973-640-0074
Fax Number	:

Authorized Official
Title or Position	:	NP
Name	:	CHINYERE OBIAKWATA
Credential	:
Telephone Number	:	973-640-0074

Provider Enumeration Date	:	04/08/2019
Last Update Date	:	04/08/2019

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