Provider Demographics
NPI:1336673177
Name:CHARLESTON GROVE, LLC
Entity Type:Organization
Organization Name:CHARLESTON GROVE, LLC
Other - Org Name:THE CHARLESTON SENIOR COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-270-7500
Mailing Address - Street 1:45 SAINT PATRICKS DR
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4507
Mailing Address - Country:US
Mailing Address - Phone:240-270-7500
Mailing Address - Fax:240-523-7410
Practice Address - Street 1:45 SAINT PATRICKS DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4507
Practice Address - Country:US
Practice Address - Phone:240-270-7500
Practice Address - Fax:240-523-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08AL0144-A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility