Healthcare Provider Details

I. General information

NPI: 1730721085
Provider Name (Legal Business Name): SERENITY MANOR ADULT DAY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 WOODBRIDGE STATION WAY STE 102
EDGEWOOD MD
21040-3852
US

IV. Provider business mailing address

1319 WOODBRIDGE STATION WAY STE 102
EDGEWOOD MD
21040-3852
US

V. Phone/Fax

Practice location:
  • Phone: 410-994-8988
  • Fax: 410-844-5686
Mailing address:
  • Phone: 410-994-8988
  • Fax: 410-844-5686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAMILLE G. MATTHEWS
Title or Position: CEO
Credential:
Phone: 410-994-8988