Provider Demographics
NPI:1760543367
Name:ASLC OPCO MD I, LLC
Entity Type:Organization
Organization Name:ASLC OPCO MD I, LLC
Other - Org Name:IVY HALL GERIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-708-1946
Mailing Address - Street 1:1300 WINDLASS DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-4126
Mailing Address - Country:US
Mailing Address - Phone:410-687-1383
Mailing Address - Fax:410-682-4174
Practice Address - Street 1:1300 WINDLASS DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220-4126
Practice Address - Country:US
Practice Address - Phone:410-687-1383
Practice Address - Fax:410-682-4174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03-019314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
215181Medicare Oscar/Certification