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General NPI Number Information
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NPI Number | 1346647898
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Entity Type | Organization
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Legal Business Name | MOUNT VERNON HEALTHCARE RESIDENCE LLC
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Dates
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Enumeration Date | 11/28/2014
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Last Update Date | 06/20/2016
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Provider Practice Location Address
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Address Line | 501 YATES ST
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City | MOUNT VERNON
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State | TX
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Zip | 75457-3233
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Country | US
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Telephone | 214-396-3462
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Fax |
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Provider Business Mailing Address
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Address Line | 111 CLIFTON AVE STE 12
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City | LAKEWOOD
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State | NJ
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Zip | 08701-3342
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Country | US
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Telephone | 214-396-3462
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | JOE NEUMAN
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Credential |
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Telephone | 214-396-3462
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 004659
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License Number State | TX
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