Basic Information
| Provider Information | |||||||||
| NPI: | 1730160805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE VINDOBONA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VINDOBONA NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 318 | ||||||||
| Address2: | |||||||||
| City: | BRADDOCK HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217140318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013717160 | ||||||||
| FaxNumber: | 3013715921 | ||||||||
| Practice Location | |||||||||
| Address1: | 6012 JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | BRADDOCK HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013717160 | ||||||||
| FaxNumber: | 3013715921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 3013717160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 10005 | MD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.