Provider Demographics
NPI:1982931440
Name:VERNON CARE LIVING INC
Entity Type:Organization
Organization Name:VERNON CARE LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GORMAH
Authorized Official - Middle Name:PINKY
Authorized Official - Last Name:KOLLEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-758-7136
Mailing Address - Street 1:1435 BOGGS RD
Mailing Address - Street 2:APARTMENT 1018
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:729 E VERNON RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1502
Practice Address - Country:US
Practice Address - Phone:215-758-7136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities