Healthcare Provider Details

I. General information

NPI: 1205050580
Provider Name (Legal Business Name): CUMBERLAND COVENANT HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11810 BEDFORD RD NE
CUMBERLAND MD
21502-6990
US

IV. Provider business mailing address

11810 BEDFORD RD NE
CUMBERLAND MD
21502-6990
US

V. Phone/Fax

Practice location:
  • Phone: 301-722-6881
  • Fax: 301-722-6690
Mailing address:
  • Phone: 301-722-6681
  • Fax: 301-722-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number10570
License Number StateMD

VIII. Authorized Official

Name: SUE L ROOT
Title or Position: CEO
Credential:
Phone: 301-722-6681