MEDICARE: JERMAINE VANN

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1194970426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERMAINE VANN

Provider Business Mailing Address
First Line	:	790 WASHINGTON AVE
Second Line	:	STE 113
City	:	BROOKLYN
State	:	NY
Zip	:	11238-4548
Country	:	US
Telephone Number	:	917-474-9277
Fax Number	:

Provider Business Practice Location Address
First Line	:	790 WASHINGTON AVE
Second Line	:	STE 113
City	:	BROOKLYN
State	:	NY
Zip	:	11238-4548
Country	:	US
Telephone Number	:	917-474-9277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2008
Last Update Date	:	12/01/2008

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