Healthcare Provider Details

I. General information

NPI: 1215141973
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

154 N ARTIZAN ST
WILLIAMSPORT MD
21795-1104
US

IV. Provider business mailing address

18100 SLADE SCHOOL RD
SANDY SPRING MD
20860-1313
US

V. Phone/Fax

Practice location:
  • Phone: 301-924-2811
  • Fax: 301-924-1200
Mailing address:
  • Phone: 301-924-2811
  • Fax: 301-924-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number21-014
License Number StateMD

VIII. Authorized Official

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