Healthcare Provider Details

I. General information

NPI: 1437162526
Provider Name (Legal Business Name): CARROLL LUTHERAN VILLAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SAINT LUKE CIR
WESTMINSTER MD
21158-4174
US

IV. Provider business mailing address

300 SAINT LUKE CIR
WESTMINSTER MD
21158-4174
US

V. Phone/Fax

Practice location:
  • Phone: 410-848-0090
  • Fax: 410-848-8133
Mailing address:
  • Phone: 410-848-0090
  • Fax: 410-848-8133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number06-012
License Number StateMD

VIII. Authorized Official

Name: MR. GEARY MILLIKEN
Title or Position: CEO / PRESIDENT
Credential:
Phone: 410-848-0090