Provider Demographics
NPI:1669743175
Name:HERON'S CREEK
Entity type:Organization
Organization Name:HERON'S CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:STACY
Authorized Official - Last Name:FAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:443-540-8949
Mailing Address - Street 1:137 LINTON RUN RD
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904-1650
Mailing Address - Country:US
Mailing Address - Phone:443-540-8949
Mailing Address - Fax:410-378-4162
Practice Address - Street 1:112 RED TOAD RD
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-2601
Practice Address - Country:US
Practice Address - Phone:443-674-8745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAL000682310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherEIN