=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790795672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERMITAGE HEALTHCARE OF MANOKIN MANOR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11974 EDGEHILL TERRACE RD
-----------------------------------------------------
City | PRINCESS ANNE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21853-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-651-0011
-----------------------------------------------------
Fax | 410-543-4471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11974 EDGEHILL TERRACE RD
-----------------------------------------------------
City | PRINCESS ANNE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21853-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-651-0011
-----------------------------------------------------
Fax | 410-543-4471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. BONNIE C. STONE
-----------------------------------------------------
Credential | LICENSED ADMINISTRAT
-----------------------------------------------------
Telephone | 410-651-0011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3140N1450X
-----------------------------------------------------
Taxonomy Name | Pediatric Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------