Provider Demographics
NPI:1376598763
Name:VINTAGE CARE INC.
Entity Type:Organization
Organization Name:VINTAGE CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAZOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-883-6744
Mailing Address - Street 1:PO BOX 436196
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40253-6196
Mailing Address - Country:US
Mailing Address - Phone:502-883-6744
Mailing Address - Fax:502-883-6743
Practice Address - Street 1:2000 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1803
Practice Address - Country:US
Practice Address - Phone:502-883-6744
Practice Address - Fax:502-883-6743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
50011327OtherPASSPORT
DF1586OtherRAILROAD MEDICARE
2742752000OtherPASSPORT ADVANTAGE
KY65945339Medicaid
50011327OtherPASSPORT