MEDICARE: VANCO 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	251B00000X	Case Management Agency	3724965	DE

General Provider Information

NPI Number	:	1316109192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANCO LLC

Provider Business Mailing Address
First Line	:	50 SHORE BLVD APT 6L
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-4040
Country	:	US
Telephone Number	:	347-702-5261
Fax Number	:	347-702-7038

Provider Business Practice Location Address
First Line	:	50 SHORE BLVD APT 6L
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-4040
Country	:	US
Telephone Number	:	347-702-5261
Fax Number	:	347-702-5261

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. DAMIAN V IVANOV
Credential	:
Telephone Number	:	347-702-5261

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	09/23/2008

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