Provider Demographics
NPI:1124074620
Name:CHERRY LANE MEDICAL INVESTORS LLC
Entity type:Organization
Organization Name:CHERRY LANE MEDICAL INVESTORS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAULIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-876-3836
Mailing Address - Street 1:9001 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1155
Mailing Address - Country:US
Mailing Address - Phone:301-498-8558
Mailing Address - Fax:301-317-1930
Practice Address - Street 1:9001 CHERRY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-1155
Practice Address - Country:US
Practice Address - Phone:301-498-8558
Practice Address - Fax:301-317-1930
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FG HEALTHCARE PROPERTYS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16-033314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MH367300600Medicaid
MH367300600Medicaid