Provider Demographics
NPI:1598736753
Name:CARROLL MANOR
Entity type:Organization
Organization Name:CARROLL MANOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONEFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-729-3500
Mailing Address - Street 1:725 BUCHANAN ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2340
Mailing Address - Country:US
Mailing Address - Phone:202-269-7100
Mailing Address - Fax:202-854-7816
Practice Address - Street 1:725 BUCHANAN ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2340
Practice Address - Country:US
Practice Address - Phone:202-269-7100
Practice Address - Fax:202-854-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD02-0027314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC029834200Medicaid
DC058490554Medicaid