=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821873209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITADEL HOME HEALTHCARE LIMITED LIABILITY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2023
-----------------------------------------------------
Last Update Date | 08/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2111 SUNBRIAR LN UNIT B
-----------------------------------------------------
City | GWYNN OAK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-5987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-929-0406
-----------------------------------------------------
Fax | 443-308-0793
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2111 SUNBRIAR LN UNIT B
-----------------------------------------------------
City | GWYNN OAK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-5987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-929-0406
-----------------------------------------------------
Fax | 443-308-0793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. SIDNEY MALCOLM WATERS
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 443-929-0406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------