Provider Demographics
NPI:1871255687
Name:DOMINION RESIDENCE OF MARYLAND,INC
Entity Type:Organization
Organization Name:DOMINION RESIDENCE OF MARYLAND,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BECHEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-624-9404
Mailing Address - Street 1:4415 NICOLE DR STE G
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4357
Mailing Address - Country:US
Mailing Address - Phone:301-624-9404
Mailing Address - Fax:
Practice Address - Street 1:4415 NICOLE DR STE G
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4357
Practice Address - Country:US
Practice Address - Phone:301-624-9404
Practice Address - Fax:301-306-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities