1770624272 NPI number — WORTHINGTON ASSISTED LIVING

Table of content: (NPI 1770624272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770624272 NPI number — WORTHINGTON ASSISTED LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORTHINGTON ASSISTED LIVING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
64 RIESTERSTOWN ROAD LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770624272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6401 DOGWOOD RD STE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21207-5248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-298-9800
Provider Business Mailing Address Fax Number:
410-298-5206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REISTERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21136-1210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-526-2146
Provider Business Practice Location Address Fax Number:
410-526-7646
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEVADOSS
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-298-9800

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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