Provider Demographics
NPI:1396185856
Name:VINTAGE TIME LLC
Entity Type:Organization
Organization Name:VINTAGE TIME LLC
Other - Org Name:HUMMINGBIRD HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CULP
Authorized Official - Suffix:
Authorized Official - Credentials:RN MS
Authorized Official - Phone:253-225-1474
Mailing Address - Street 1:26 E KAYETAN DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-1116
Mailing Address - Country:US
Mailing Address - Phone:253-225-1474
Mailing Address - Fax:
Practice Address - Street 1:1448 HUMMINGBIRD LN
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-5443
Practice Address - Country:US
Practice Address - Phone:520-335-2001
Practice Address - Fax:520-335-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7415H311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ429252Medicaid