MEDICARE: VANILLA MANAGEMENT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1043453889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANILLA MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	20 EXPEDITION TRL
Second Line	:	SUITE 102
City	:	GETTYSBURG
State	:	PA
Zip	:	17325-8598
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 EXPEDITION TRL
Second Line	:	SUITE 102
City	:	GETTYSBURG
State	:	PA
Zip	:	17325-8598
Country	:	US
Telephone Number	:	717-515-9652
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ROBIN SHAH
Credential	:
Telephone Number	:	717-515-9652

Provider Enumeration Date	:	04/09/2009
Last Update Date	:	04/09/2009

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