Provider Demographics
NPI:1104096130
Name:BROADOR HORIZON, INC
Entity type:Organization
Organization Name:BROADOR HORIZON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MATTISON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:443-413-0832
Mailing Address - Street 1:199 PLYMOUTH LN
Mailing Address - Street 2:F
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 PLYMOUTH LN
Practice Address - Street 2:F
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5652
Practice Address - Country:US
Practice Address - Phone:443-413-0832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0290315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities