Provider Demographics
NPI:1538142146
Name:ASBURY ATLANTIC, INC
Entity Type:Organization
Organization Name:ASBURY ATLANTIC, INC
Other - Org Name:HERMAN M. WILSON HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DENTON
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:301-216-4021
Mailing Address - Street 1:301 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2805
Practice Address - Country:US
Practice Address - Phone:301-216-4222
Practice Address - Fax:301-216-5752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15-022314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21-5099Medicare ID - Type Unspecified