Healthcare Provider Details

I. General information

NPI: 1265219968
Provider Name (Legal Business Name): GREAT HEARTS ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 N STOCKTON ST
BALTIMORE MD
21217-2647
US

IV. Provider business mailing address

1105 N STOCKTON ST
BALTIMORE MD
21217-2647
US

V. Phone/Fax

Practice location:
  • Phone: 202-615-3377
  • Fax:
Mailing address:
  • Phone: 202-615-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name: AMBER ADGERSON
Title or Position: OWNER/DELEGATING NURSE
Credential:
Phone: 202-615-3377