Healthcare Provider Details

I. General information

NPI: 1750595518
Provider Name (Legal Business Name): BROOKE GROVE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18131 SLADE SCHOOL RD
SANDY SPRING MD
20860-1346
US

IV. Provider business mailing address

18100 SLADE SCHOOL RD
SANDY SPRING MD
20860-1313
US

V. Phone/Fax

Practice location:
  • Phone: 301-924-5176
  • Fax:
Mailing address:
  • Phone: 301-924-5176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number15-005
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15516710000
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: KEITH SPILLANE
Title or Position: DIR. CORP. FINANCE
Credential:
Phone: 301-388-7204