Provider Demographics
NPI:1366903551
Name:VANTAGE HEALTHCARE LLC
Entity type:Organization
Organization Name:VANTAGE HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-867-2050
Mailing Address - Street 1:PO BOX 620550
Mailing Address - Street 2:
Mailing Address - City:NEWTON LOWER FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:02462-0550
Mailing Address - Country:US
Mailing Address - Phone:781-867-2050
Mailing Address - Fax:
Practice Address - Street 1:45 DAN RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021
Practice Address - Country:US
Practice Address - Phone:781-867-2050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-29
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3118438Medicaid
MA110153150AMedicaid