MEDICARE: VERTEX SOUTH 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	101YM0800X	Mental Health Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1780265447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VERTEX SOUTH LLC

Provider Business Mailing Address
First Line	:	1080 E GUN HILL RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-3742
Country	:	US
Telephone Number	:	718-653-1117
Fax Number	:

Provider Business Practice Location Address
First Line	:	2409 DAN AND MARY ST
Second Line	:
City	:	ELIZABETH CTY
State	:	NC
Zip	:	27909-9085
Country	:	US
Telephone Number	:	718-653-1117
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. ZOYA GORNOPOLSKY
Credential	:
Telephone Number	:	718-653-1117

Provider Enumeration Date	:	04/15/2021
Last Update Date	:	04/15/2021

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Directions to “VERTEX SOUTH LLC ” Practice Location

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