Provider Demographics
NPI:1891070645
Name:VILLA BELLE MOON ASSISTED LIVING INC
Entity Type:Organization
Organization Name:VILLA BELLE MOON ASSISTED LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTED LIVING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:MONA
Authorized Official - Last Name:VIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:240-644-8399
Mailing Address - Street 1:6305 TUCKERMAN LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3511
Mailing Address - Country:US
Mailing Address - Phone:240-463-7196
Mailing Address - Fax:
Practice Address - Street 1:6305 TUCKERMAN LN
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3511
Practice Address - Country:US
Practice Address - Phone:240-463-7196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15AL0446-A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility