Healthcare Provider Details

I. General information

NPI: 1467585687
Provider Name (Legal Business Name): KEITH RONALD VERNON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 GOOD LUCK RD
LANHAM MD
20706-3511
US

IV. Provider business mailing address

7172 HANOVER PKWY
GREENBELT MD
20770-2005
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-2000
  • Fax:
Mailing address:
  • Phone: 202-361-0225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA1738
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: