Provider Demographics
NPI:1386075919
Name:NEW VANTAGE LLC
Entity type:Organization
Organization Name:NEW VANTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SIREECE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-829-3034
Mailing Address - Street 1:21379 TULANE AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5670
Mailing Address - Country:US
Mailing Address - Phone:313-829-3034
Mailing Address - Fax:
Practice Address - Street 1:21379 TULANE AVE APT 201
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5670
Practice Address - Country:US
Practice Address - Phone:313-829-3034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-08
Last Update Date:2013-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health