Healthcare Provider Details

I. General information

NPI: 1336371236
Provider Name (Legal Business Name): VITAL SUPPORT SUPPORT COORDINATION AGENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 TOWNSHIP LINE RD SUITE 201
ELKINS PARK PA
19027-2272
US

IV. Provider business mailing address

333 TOWNSHIP LINE RD SUITE 201
ELKINS PARK PA
19027-2272
US

V. Phone/Fax

Practice location:
  • Phone: 215-379-3300
  • Fax: 215-379-3400
Mailing address:
  • Phone: 215-379-3300
  • Fax: 215-379-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. VARELINE VAZQUEZ
Title or Position: CEO
Credential:
Phone: 215-379-3300