Basic Information
| Provider Information | |||||||||
| NPI: | 1740365394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY WASHINGTON CONVALESCENT & NURSING CARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARY WASHINGTON REHABILITATION & HEALTH CARE LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12093 GAYTON RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232383401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045210550 | ||||||||
| FaxNumber: | 8045210555 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 MCKINNEY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLONIAL BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224431237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042242222 | ||||||||
| FaxNumber: | 8042242282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ADELMAN | ||||||||
| AuthorizedOfficialFirstName: | GRAHAM | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8045210550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2627 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 139149 | 01 | VA | BCBS PROVIDER NUMBER | OTHER |