Healthcare Provider Details

I. General information

NPI: 1730160805
Provider Name (Legal Business Name): THE VINDOBONA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6012 JEFFERSON BLVD
BRADDOCK HEIGHTS MD
21714
US

IV. Provider business mailing address

PO BOX 318
BRADDOCK HEIGHTS MD
21714-0318
US

V. Phone/Fax

Practice location:
  • Phone: 301-371-7160
  • Fax: 301-371-5921
Mailing address:
  • Phone: 301-371-7160
  • Fax: 301-371-5921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10005
License Number StateMD

VIII. Authorized Official

Name: MR. RANDALL SCOTT MARTIN
Title or Position: SECRETARY/TREASURER
Credential:
Phone: 301-371-7160