Provider Demographics
NPI:1770870123
Name:VERNON HEALTHCARE PROVIDERS
Entity type:Organization
Organization Name:VERNON HEALTHCARE PROVIDERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:WATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-267-2861
Mailing Address - Street 1:4301 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-3135
Mailing Address - Country:US
Mailing Address - Phone:940-552-2568
Mailing Address - Fax:940-552-6256
Practice Address - Street 1:4301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-3135
Practice Address - Country:US
Practice Address - Phone:940-552-2568
Practice Address - Fax:940-552-6256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX668850000261QR0401X
TX561710000261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675412Medicare UPIN