=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619200235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GILMO RESIDENTIAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2009
-----------------------------------------------------
Last Update Date | 09/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4803 HAWKSBURY RD
-----------------------------------------------------
City | PIKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-963-2559
-----------------------------------------------------
Fax | 410-521-0579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4803 HAWKSBURY RD
-----------------------------------------------------
City | PIKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-963-2559
-----------------------------------------------------
Fax | 410-521-0579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. GILLIAN ISIDAHOMEN
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 410-963-2559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | R2762
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------