Provider Demographics
NPI:1679718407
Name:VINTAGE SCC LLC
Entity type:Organization
Organization Name:VINTAGE SCC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-436-4343
Mailing Address - Street 1:205 N BONNIE BRAE ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-3766
Mailing Address - Country:US
Mailing Address - Phone:940-373-4766
Mailing Address - Fax:940-320-6645
Practice Address - Street 1:205 N BONNIE BRAE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-3766
Practice Address - Country:US
Practice Address - Phone:940-373-4766
Practice Address - Fax:940-320-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001017205Medicaid
TX000544OtherFACILITY ID