Provider Demographics
NPI:1437162526
Name:CARROLL LUTHERAN VILLAGE INC
Entity Type:Organization
Organization Name:CARROLL LUTHERAN VILLAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLIKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-848-0090
Mailing Address - Street 1:300 SAINT LUKE CIR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21158-4174
Mailing Address - Country:US
Mailing Address - Phone:410-848-0090
Mailing Address - Fax:410-848-8133
Practice Address - Street 1:300 SAINT LUKE CIR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21158-4174
Practice Address - Country:US
Practice Address - Phone:410-848-0090
Practice Address - Fax:410-848-8133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06-012314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD57596102OtherCAREFIRST
MDMP7OtherFEDERAL BLUE CROSS
MD063417400Medicaid
MDMP7OtherFEDERAL BLUE CROSS