Healthcare Provider Details

I. General information

NPI: 1790795672
Provider Name (Legal Business Name): HERMITAGE HEALTHCARE OF MANOKIN MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11974 EDGEHILL TERRACE RD
PRINCESS ANNE MD
21853-2105
US

IV. Provider business mailing address

11974 EDGEHILL TERRACE RD
PRINCESS ANNE MD
21853-2105
US

V. Phone/Fax

Practice location:
  • Phone: 410-651-0011
  • Fax: 410-543-4471
Mailing address:
  • Phone: 410-651-0011
  • Fax: 410-543-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. BONNIE C. STONE
Title or Position: ADMINISTRATOR
Credential: LICENSED ADMINISTRAT
Phone: 410-651-0011