MEDICARE: MRS. KIM MABEL VERNON

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	156FX1800X	Optician	D-2181	NJ

General Provider Information

NPI Number	:	1508958703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM MABEL VERNON

Provider Business Mailing Address
First Line	:	1230 CHEWS LANDING RD
Second Line	:
City	:	LAUREL SPRINGS
State	:	NJ
Zip	:	08021-2804
Country	:	US
Telephone Number	:	856-784-1222
Fax Number	:	856-784-0068

Provider Business Practice Location Address
First Line	:	1230 CHEWS LANDING RD
Second Line	:
City	:	LAUREL SPRINGS
State	:	NJ
Zip	:	08021-2804
Country	:	US
Telephone Number	:	856-784-1222
Fax Number	:	856-784-0068

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	07/08/2007

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