Provider Demographics
NPI:1679132252
Name:10 OLD DOMINION OPERATIONS, LLC
Entity type:Organization
Organization Name:10 OLD DOMINION OPERATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-595-6025
Mailing Address - Street 1:10 OLD DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-4611
Mailing Address - Country:US
Mailing Address - Phone:410-333-3393
Mailing Address - Fax:
Practice Address - Street 1:10 OLD DIAMOND HILL RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-4611
Practice Address - Country:US
Practice Address - Phone:410-333-3393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility