MEDICARE: PROSPECT NURSING HOME, INC.

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	314000000X	Skilled Nursing Facility	0270000217	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205880150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSPECT NURSING HOME, INC.

Provider Business Mailing Address
First Line	:	PO BOX 878
Second Line	:
City	:	NORTH BENNINGTON
State	:	VT
Zip	:	05257-0878
Country	:	US
Telephone Number	:	802-447-7144
Fax Number	:	802-447-3044

Provider Business Practice Location Address
First Line	:	20 PROSPECT ST
Second Line	:
City	:	NORTH BENNINGTON
State	:	VT
Zip	:	05257-9544
Country	:	US
Telephone Number	:	802-447-7144
Fax Number	:	802-447-3044

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PETER J. MORRIS
Credential	:	MBA
Telephone Number	:	802-447-7144

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	08/14/2007

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