Provider Demographics
NPI:1134468150
Name:BRADDOCK HEIGHTS HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BRADDOCK HEIGHTS HEALTHCARE, LLC
Other - Org Name:VINDOBONA NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-308-1845
Mailing Address - Street 1:7201 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2780
Mailing Address - Country:US
Mailing Address - Phone:423-308-1845
Mailing Address - Fax:423-308-1848
Practice Address - Street 1:6012 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-6953
Practice Address - Country:US
Practice Address - Phone:301-371-7160
Practice Address - Fax:301-371-5921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10-005314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4215885 00Medicaid
MD4215885 00Medicaid