Provider Demographics
NPI:1790394161
Name:MODERN VINTAGE RESIDENTIAL CARE, LLC.
Entity Type:Organization
Organization Name:MODERN VINTAGE RESIDENTIAL CARE, LLC.
Other - Org Name:MODERN VINTAGE HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-886-6717
Mailing Address - Street 1:3 SUGAR CREEK CENTER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-2211
Mailing Address - Country:US
Mailing Address - Phone:832-886-6717
Mailing Address - Fax:833-529-0204
Practice Address - Street 1:3 SUGAR CREEK CENTER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-2211
Practice Address - Country:US
Practice Address - Phone:832-886-6717
Practice Address - Fax:833-529-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX415779401Medicaid