=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336598390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINDRED REHAB CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2016
-----------------------------------------------------
Last Update Date | 07/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3320 BENSON AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21227-1035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-646-6501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3320 BENSON AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-646-6501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | AMANDA POPP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-591-5808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 24829
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------