MEDICARE: VANNESS ENTERPRISES, 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	133NN1002X	Nutrition Education Nutritionist
2	101YM0800X	Mental Health Counselor
3	208D00000X	General Practice Physician	32854	CO

General Provider Information

NPI Number	:	1508198565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANNESS ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	4740 FLINTRIDGE DR STE 101
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-4254
Country	:	US
Telephone Number	:	719-510-6313
Fax Number	:	719-358-7756

Provider Business Practice Location Address
First Line	:	4740 FLINTRIDGE DR STE 101
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-4254
Country	:	US
Telephone Number	:	719-510-6313
Fax Number	:	719-358-7756

Authorized Official
Title or Position	:	CEO
Name	:	RANDEE P VAN NESS
Credential	:	MS
Telephone Number	:	719-651-5102

Provider Enumeration Date	:	02/02/2010
Last Update Date	:	07/09/2010

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