Healthcare Provider Details

I. General information

NPI: 1639771165
Provider Name (Legal Business Name): SUPERIOR ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4134 W FOREST PARK AVE
GWYNN OAK MD
21207-7407
US

IV. Provider business mailing address

8201 HARFORD RD UNIT 8417
PARKVILLE MD
21234-7545
US

V. Phone/Fax

Practice location:
  • Phone: 443-800-2530
  • Fax: 443-378-5700
Mailing address:
  • Phone: 410-800-2530
  • Fax: 443-378-5700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MS. LORRIE REGINA DAVIS
Title or Position: PRESIDENT
Credential:
Phone: 443-468-2101