Healthcare Provider Details

I. General information

NPI: 1760543367
Provider Name (Legal Business Name): ASLC OPCO MD I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 WINDLASS DR
BALTIMORE MD
21220-4126
US

IV. Provider business mailing address

1300 WINDLASS DR
BALTIMORE MD
21220-4126
US

V. Phone/Fax

Practice location:
  • Phone: 410-687-1383
  • Fax: 410-682-4174
Mailing address:
  • Phone: 410-687-1383
  • Fax: 410-682-4174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number03-019
License Number StateMD

VIII. Authorized Official

Name: MR. ROBERT V GIBBS
Title or Position: PRESIDENT
Credential:
Phone: 732-708-1946