Basic Information
| Provider Information | |||||||||
| NPI: | 1982641809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THI OF MARYLAND AT LIBERTY HEIGHTS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIBERTY HEIGHTS HEALTH AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4017 LIBERTY HEIGHTS AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212077545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105425306 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 09/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOX | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 4107731000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 30-022 | MD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.