Provider Demographics
NPI:1861459430
Name:DIAKON LUTHERAN SENIOR LIVING - MARYLAND LLC
Entity Type:Organization
Organization Name:DIAKON LUTHERAN SENIOR LIVING - MARYLAND LLC
Other - Org Name:RAVENWOOD LUTHERAN VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP, FINANCIAL PLANNING & OPE
Authorized Official - Prefix:
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-795-0364
Mailing Address - Street 1:1022 NORTH UNION STREET
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17057-2158
Mailing Address - Country:US
Mailing Address - Phone:717-795-0386
Mailing Address - Fax:717-795-0353
Practice Address - Street 1:1183 LUTHER DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7407
Practice Address - Country:US
Practice Address - Phone:240-420-4133
Practice Address - Fax:240-420-4218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2175479P0005Medicaid
MD421699700Medicaid
MD7563001P0002Medicaid