Healthcare Provider Details

I. General information

NPI: 1053069146
Provider Name (Legal Business Name): PLATINUM NURSING AND ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 REAL PRINCESS LN
BALTIMORE MD
21207-4578
US

IV. Provider business mailing address

6900 REAL PRINCESS LN
BALTIMORE MD
21207-4578
US

V. Phone/Fax

Practice location:
  • Phone: 410-240-3695
  • Fax:
Mailing address:
  • Phone: 410-240-3695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. DESHA RENEE JONES
Title or Position: OWNER/OPERATOR
Credential:
Phone: 410-240-3695