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General NPI Number Information
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NPI Number | 1336673177
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Entity Type | Organization
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Legal Business Name | CHARLESTON GROVE, LLC
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Dates
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Enumeration Date | 04/19/2017
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Last Update Date | 04/19/2017
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Provider Practice Location Address
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Address Line | 45 SAINT PATRICKS DR
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City | WALDORF
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State | MD
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Zip | 20603-4507
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Country | US
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Telephone | 240-270-7500
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Fax | 240-523-7410
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Provider Business Mailing Address
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Address Line | 45 SAINT PATRICKS DR
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City | WALDORF
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State | MD
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Zip | 20603-4507
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Country | US
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Telephone | 240-270-7500
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Fax | 240-523-7410
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. PATRICK GOFF
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Credential |
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Telephone | 240-270-7500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 08AL0144-A
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License Number State | MD
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