Healthcare Provider Details

I. General information

NPI: 1265628085
Provider Name (Legal Business Name): JEFFON SENIR CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2007
Last Update Date: 09/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 BERRYWOOD LN
SPRINGDALE MD
20774-7514
US

IV. Provider business mailing address

2620 BERRYWOOD LN
SPRINGDALE MD
20774-7514
US

V. Phone/Fax

Practice location:
  • Phone: 240-770-7921
  • Fax:
Mailing address:
  • Phone: 240-770-7921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number0609009
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number060909
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number060909
License Number StateMD

VIII. Authorized Official

Name: MR. LUCAS N FON
Title or Position: DIRECTOR
Credential:
Phone: 240-461-8569