Provider Demographics
NPI:1629225107
Name:VINTAGE PARK AT EUREKA, LLC
Entity Type:Organization
Organization Name:VINTAGE PARK AT EUREKA, LLC
Other - Org Name:VINTAGE PARK AT EUREKA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-282-5800
Mailing Address - Street 1:1820 E RIVER ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:KS
Mailing Address - Zip Code:67045-2156
Mailing Address - Country:US
Mailing Address - Phone:620-583-7473
Mailing Address - Fax:620-583-7574
Practice Address - Street 1:1820 E RIVER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:KS
Practice Address - Zip Code:67045-2156
Practice Address - Country:US
Practice Address - Phone:620-583-7473
Practice Address - Fax:620-583-7574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSBEING APPLIED FOR310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSBEING APPLIED FORMedicaid