=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306275805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAM MOUNT VERNON TE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2013
-----------------------------------------------------
Last Update Date | 11/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3709 SHANNONS GREEN WAY
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22309-3659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-780-7100
-----------------------------------------------------
Fax | 703-780-5771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 PLAINFIELD AVE STE 200
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08817-2598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-582-0400
-----------------------------------------------------
Fax | 908-378-1690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | TOM VELLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-582-0400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | ALF 1104029-L152
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------