Provider Demographics
NPI:1659395424
Name:VINTAGE PARK AT PAOLA LLC
Entity Type:Organization
Organization Name:VINTAGE PARK AT PAOLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-239-0660
Mailing Address - Street 1:601 N EAST ST
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1183
Mailing Address - Country:US
Mailing Address - Phone:913-557-0202
Mailing Address - Fax:913-294-5187
Practice Address - Street 1:601 N EAST ST
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-1183
Practice Address - Country:US
Practice Address - Phone:913-557-0202
Practice Address - Fax:913-294-5187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN069009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility