Provider Demographics
NPI:1316945181
Name:19301 WATKINS MILL ROAD OPERATING COMPANY, LLC
Entity type:Organization
Organization Name:19301 WATKINS MILL ROAD OPERATING COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP & GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:A.
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4000
Mailing Address - Street 1:19301 WATKINS MILL RD.
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886
Mailing Address - Country:US
Mailing Address - Phone:301-527-2500
Mailing Address - Fax:301-527-2525
Practice Address - Street 1:19301 WATKINS MILL RD.
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886
Practice Address - Country:US
Practice Address - Phone:301-527-2500
Practice Address - Fax:301-527-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402642000Medicaid
MD402642000Medicaid