Provider Demographics
NPI:1912390329
Name:THE SUPPOERT CENTER
Entity type:Organization
Organization Name:THE SUPPOERT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MUDAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:301-738-2250
Mailing Address - Street 1:1010 GRANDIN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20851-1300
Mailing Address - Country:US
Mailing Address - Phone:301-738-2250
Mailing Address - Fax:301-309-1797
Practice Address - Street 1:1010 GRANDIN AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20851-1300
Practice Address - Country:US
Practice Address - Phone:301-738-2250
Practice Address - Fax:301-309-1797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)