MEDICARE: VERNON CARE LIVING INC

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1982931440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VERNON CARE LIVING INC

Provider Business Mailing Address
First Line	:	1435 BOGGS RD
Second Line	:	APARTMENT 1018
City	:	DULUTH
State	:	GA
Zip	:	30096-1201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	729 E VERNON RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-1502
Country	:	US
Telephone Number	:	215-758-7136
Fax Number	:

Authorized Official
Title or Position	:	PART OWNER
Name	:	MISS GORMAH PINKY KOLLEH
Credential	:
Telephone Number	:	215-758-7136

Provider Enumeration Date	:	11/04/2009
Last Update Date	:	11/04/2009

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