Provider Demographics
NPI:1720025489
Name:GOODWILL MENNONITE HOME, INC.
Entity Type:Organization
Organization Name:GOODWILL MENNONITE HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-895-5194
Mailing Address - Street 1:891 DORSEY HOTEL RD
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21536-1369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:891 DORSEY HOTEL RD
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21536-1369
Practice Address - Country:US
Practice Address - Phone:301-895-5194
Practice Address - Fax:301-895-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11-003314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21-5250Medicare ID - Type Unspecified