Basic Information
| Provider Information | |||||||||
| NPI: | 1083891220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON (MD) LEASING CO., LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH RIVER HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 ASHWOOD DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452412465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134897100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 144 WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWATER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210371412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109565000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUBBARD | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF A/R | ||||||||
| AuthorizedOfficialTelephone: | 5135301327 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 414425200 | 05 | MD | MEDICAID |