Provider Demographics
NPI:1750831376
Name:RANDALLSTOWN HEALTH CARE LLC
Entity Type:Organization
Organization Name:RANDALLSTOWN HEALTH CARE LLC
Other - Org Name:CHAPEL HILL NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEDEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-922-2443
Mailing Address - Street 1:4511 ROBOSSON RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-1018
Mailing Address - Country:US
Mailing Address - Phone:410-922-2443
Mailing Address - Fax:410-922-4822
Practice Address - Street 1:4511 ROBOSSON RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-1018
Practice Address - Country:US
Practice Address - Phone:410-922-2443
Practice Address - Fax:410-922-4822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD600112200Medicaid
215220Medicare Oscar/Certification