Basic Information
| Provider Information | |||||||||
| NPI: | 1467585687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERNON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | RONALD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7172 HANOVER PKWY | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207702005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023610225 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8200 GOOD LUCK RD | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207063511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015522000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A1738 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.