Healthcare Provider Details

I. General information

NPI: 1487946828
Provider Name (Legal Business Name): SCOTLAND MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BOARMAN AVE
BALTIMORE MD
21215-6610
US

IV. Provider business mailing address

2900 BOARMAN AVE
BALTIMORE MD
21215-6610
US

V. Phone/Fax

Practice location:
  • Phone: 443-205-7422
  • Fax: 410-366-2108
Mailing address:
  • Phone: 443-205-7422
  • Fax: 410-366-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number30AL2686-B
License Number StateMD

VIII. Authorized Official

Name: MS. LARAE RENETTE WILSON
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 443-205-7422