=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427322551
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORNINGSIDE HOUSE OF ST. CHARLES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2012
-----------------------------------------------------
Last Update Date | 03/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 VILLAGE ST
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20602-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-645-2776
-----------------------------------------------------
Fax | 301-645-0229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 VILLAGE ST
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20602-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-645-2776
-----------------------------------------------------
Fax | 301-645-0229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | MS. KELLY MASON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-669-7804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------