Healthcare Provider Details

I. General information

NPI: 1861638470
Provider Name (Legal Business Name): FB PEYTON ROCK OF AGING,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 CLARKVIEW RD SUITE 100B
BALTIMORE MD
21209-2133
US

IV. Provider business mailing address

1421 CLARKVIEW RD SUITE 100B
BALTIMORE MD
21209-2133
US

V. Phone/Fax

Practice location:
  • Phone: 410-583-1944
  • Fax: 410-583-1966
Mailing address:
  • Phone: 410-583-1944
  • Fax: 410-583-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number081001
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0810001
License Number StateMD

VIII. Authorized Official

Name: FBRADLEY PEYTON
Title or Position: PRESIDENT/OWNER
Credential: J.D., M.DIV.
Phone: 410-583-1944