Basic Information
| Provider Information | |||||||||
| NPI: | 1023102019 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLY CROSS CARENET INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SANCTUARY AT HOLY CROSS BURTONSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9184 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483339184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345428300 | ||||||||
| FaxNumber: | 7345428384 | ||||||||
| Practice Location | |||||||||
| Address1: | 3415 GREENCASTLE RD | ||||||||
| Address2: | |||||||||
| City: | BURTONSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208661715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013881400 | ||||||||
| FaxNumber: | 3018794512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBBINS | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7345428348 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 15-071 15633 | MD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 41700900 | 05 | MD | MEDICAID | 9511016 00 | 05 | MD | MEDICAID |