Provider Demographics
NPI:1497456545
Name:VINTAGE VITALITY LLC
Entity Type:Organization
Organization Name:VINTAGE VITALITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ALTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:CHHP
Authorized Official - Phone:973-704-0196
Mailing Address - Street 1:516 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2244
Mailing Address - Country:US
Mailing Address - Phone:973-704-0196
Mailing Address - Fax:
Practice Address - Street 1:516 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2244
Practice Address - Country:US
Practice Address - Phone:973-704-0196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty