Provider Demographics
NPI:1841694650
Name:VINTAGE VIEW FARM INC
Entity type:Organization
Organization Name:VINTAGE VIEW FARM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-242-1110
Mailing Address - Street 1:7230 W HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1002
Mailing Address - Country:US
Mailing Address - Phone:262-242-1110
Mailing Address - Fax:262-236-9589
Practice Address - Street 1:7230 W HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-1002
Practice Address - Country:US
Practice Address - Phone:262-242-1110
Practice Address - Fax:262-236-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
WI305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0100OtherNA