Basic Information
| Provider Information | |||||||||
| NPI: | 1316945181 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 19301 WATKINS MILL ROAD OPERATING COMPANY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MONTGOMERY VILLAGE HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19301 WATKINS MILL RD. | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY VILLAGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015272500 | ||||||||
| FaxNumber: | 3015272525 | ||||||||
| Practice Location | |||||||||
| Address1: | 19301 WATKINS MILL RD. | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY VILLAGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015272500 | ||||||||
| FaxNumber: | 3015272525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LUGO | ||||||||
| AuthorizedOfficialFirstName: | A. | ||||||||
| AuthorizedOfficialMiddleName: | ALBERTO | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP & GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 2012424000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | MD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 402642000 | 05 | MD | MEDICAID |