MEDICARE: VERNELL KING ENTRPRISE LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1255121307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VERNELL KING ENTRPRISE LLC

Provider Business Mailing Address
First Line	:	1100 KINGS ROAD
Second Line	:	UNIT 2785
City	:	JACKSONVILLE
State	:	FL
Zip	:	32203-2785
Country	:	US
Telephone Number	:	904-467-0737
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 KINGS ROAD
Second Line	:	UNIT 2785
City	:	JACKSONVILLE
State	:	FL
Zip	:	32203-2785
Country	:	US
Telephone Number	:	904-467-0737
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. VERNELL KING
Credential	:
Telephone Number	:	904-467-0737

Provider Enumeration Date	:	05/12/2025
Last Update Date	:	05/12/2025

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