Basic Information
| Provider Information | |||||||||
| NPI: | 1336142702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALVERT MANOR HEALTHCARE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1881 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | RISING SUN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219112018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106586555 | ||||||||
| FaxNumber: | 4106589717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1881 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | RISING SUN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219112018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106586555 | ||||||||
| FaxNumber: | 4106589717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CULBERSON | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4106586555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 07AL0010 | MD | X | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | 07001 | MD | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 02WZ | 01 | MD | BC/BS OF ILLINOIS | OTHER | 02WZ | 01 | MD | BC/BS OF WEST VIRGINIA | OTHER | 02WZ | 01 | MD | FREESTATE HEALTH PLAN | OTHER | 59003901 | 01 | MD | MARYLAND BC/BS | OTHER | 69010000100322 | 01 | MD | BC/BS GENERAL MOTORS | OTHER | 02WZ | 01 | MD | EMPIRE BC/BS | OTHER | 02WZ | 01 | MD | IOWA BC/BS | OTHER | 30018856 | 01 | MD | KEYSTONE MERCY | OTHER | 69010000100322 | 01 | MD | BC/BS NATIONAL ACCOUNT | OTHER | 02WZ | 01 | MD | BC/BS OF MICHIGAN | OTHER | 953268980035 | 01 | MD | TRI CARE FOR LIFE | OTHER | 615806 | 01 | MD | COMBINED INSURANCE CO | OTHER |