1134468150 NPI number — BRADDOCK HEIGHTS HEALTHCARE, LLC

Table of content: MRS. ELISE COTE LAPLANTE M.S. CCC-SLP (NPI 1114233129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134468150 NPI number — BRADDOCK HEIGHTS HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADDOCK HEIGHTS HEALTHCARE, LLC
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:
VINDOBONA NURSING AND REHABILITATION CENTER
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:
1134468150
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7201 SHALLOWFORD RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-2780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-308-1845
Provider Business Mailing Address Fax Number:
423-308-1848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6012 JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21703-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-371-7160
Provider Business Practice Location Address Fax Number:
301-371-5921
Provider Enumeration Date:
02/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
423-308-1845

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  10-005 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4215885 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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