Healthcare Provider Details

I. General information

NPI: 1720025489
Provider Name (Legal Business Name): GOODWILL MENNONITE HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 DORSEY HOTEL RD
GRANTSVILLE MD
21536-1369
US

IV. Provider business mailing address

891 DORSEY HOTEL RD
GRANTSVILLE MD
21536-1369
US

V. Phone/Fax

Practice location:
  • Phone: 301-895-5194
  • Fax: 301-895-3704
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number11-003
License Number StateMD

VIII. Authorized Official

Name: KEVIN MILLER
Title or Position: CEO
Credential:
Phone: 301-895-5194