Basic Information
| Provider Information | |||||||||
| NPI: | 1790795672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERMITAGE HEALTHCARE OF MANOKIN MANOR, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANOKIN MANOR NURSING & REHAB CTR. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11974 EDGEHILL TERRACE RD | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218532105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106510011 | ||||||||
| FaxNumber: | 4105434471 | ||||||||
| Practice Location | |||||||||
| Address1: | 11974 EDGEHILL TERRACE RD | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218532105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106510011 | ||||||||
| FaxNumber: | 4105434471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4106510011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LICENSED ADMINISTRAT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3140N1450X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 19002 | 05 | MD | MEDICAID |