MEDICARE: KIPP WEST PHILADELPHIA PREP CHARTER SCHOOL

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	251300000X	Local Education Agency (LEA)		PA

General Provider Information

NPI Number	:	1912283573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIPP WEST PHILADELPHIA PREP CHARTER SCHOOL

Provider Business Mailing Address
First Line	:	5900 BALTIMORE AVE
Second Line	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3129
Country	:	US
Telephone Number	:	215-852-1532
Fax Number	:	215-827-5942

Provider Business Practice Location Address
First Line	:	5900 BALTIMORE AVE
Second Line	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3129
Country	:	US
Telephone Number	:	215-852-1532
Fax Number	:	215-827-5942

Authorized Official
Title or Position	:	CHIEF EXEC. OFFICER
Name	:	MS. SHAWNA P WELLS
Credential	:	MED
Telephone Number	:	215-847-5951

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	10/27/2011

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