Provider Demographics
NPI:1134243660
Name:VINTAGE PLACE OF RUSSELL, INC.
Entity type:Organization
Organization Name:VINTAGE PLACE OF RUSSELL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCKERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-483-5882
Mailing Address - Street 1:1070 E WICHITA AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KS
Mailing Address - Zip Code:67665-2452
Mailing Address - Country:US
Mailing Address - Phone:785-483-5882
Mailing Address - Fax:785-483-2797
Practice Address - Street 1:1070 E WICHITA AVE
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KS
Practice Address - Zip Code:67665-2452
Practice Address - Country:US
Practice Address - Phone:785-483-5882
Practice Address - Fax:785-483-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN-084-007310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility