Provider Demographics
NPI:1790795672
Name:HERMITAGE HEALTHCARE OF MANOKIN MANOR, LLC
Entity Type:Organization
Organization Name:HERMITAGE HEALTHCARE OF MANOKIN MANOR, LLC
Other - Org Name:MANOKIN MANOR NURSING & REHAB CTR.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED ADMINISTRAT
Authorized Official - Phone:410-651-0011
Mailing Address - Street 1:11974 EDGEHILL TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:PRINCESS ANNE
Mailing Address - State:MD
Mailing Address - Zip Code:21853-2105
Mailing Address - Country:US
Mailing Address - Phone:410-651-0011
Mailing Address - Fax:410-543-4471
Practice Address - Street 1:11974 EDGEHILL TERRACE RD
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853-2105
Practice Address - Country:US
Practice Address - Phone:410-651-0011
Practice Address - Fax:410-543-4471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD19002Medicaid
MD19002Medicaid