Organization
VINTAGE CARE INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BONNIE A LAZOR MD (OWNER/PHYSICIAN)
(502) 883-6744
Entity
Organization
Contact information
Practice address
2000 NEWBURG RD, LOUISVILLE, KY 40205-1803
(502) 883-6744
(502) 883-6743
Mailing address
PO BOX 436196, LOUISVILLE, KY 40253-6196
(502) 883-6744
(502) 883-6743
Taxonomy
Speciality
Code
Description
License number
State
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
Primary
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2742752000
PASSPORT ADVANTAGE
—
01
—
50011327
PASSPORT
—
05
—
65945339
—
KY
01
—
DF1586
RAILROAD MEDICARE
—
Enumeration date
05/23/2006
Last updated
10/19/2016
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