Provider Demographics
NPI:1629323167
Name:VINTAGE HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:VINTAGE HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ENO
Authorized Official - Middle Name:
Authorized Official - Last Name:AKANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-517-0191
Mailing Address - Street 1:7 BLANCHARD CIR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-2037
Mailing Address - Country:US
Mailing Address - Phone:630-517-0191
Mailing Address - Fax:630-260-1035
Practice Address - Street 1:7 BLANCHARD CIR
Practice Address - Street 2:SUITE 103
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-2037
Practice Address - Country:US
Practice Address - Phone:630-517-0191
Practice Address - Fax:630-260-1035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL4000250251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1010816Medicaid