Healthcare Provider Details

I. General information

NPI: 1740261692
Provider Name (Legal Business Name): CHARLES COUNTY NURSING HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 LAPLATA RD
LA PLATA MD
20646-3245
US

IV. Provider business mailing address

10200 LAPLATA RD
LA PLATA MD
20646-3245
US

V. Phone/Fax

Practice location:
  • Phone: 301-934-1900
  • Fax: 301-539-7310
Mailing address:
  • Phone: 301-934-1900
  • Fax: 301-539-7310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number08003
License Number StateMD

VIII. Authorized Official

Name: MR. WILLIAM M HOLMAN JR.
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 301-934-1900