Healthcare Provider Details

I. General information

NPI: 1821324849
Provider Name (Legal Business Name): PEACE & GLORY MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3829 KILBURN RD
RANDALLSTOWN MD
21133-4655
US

IV. Provider business mailing address

3829 KILBURN RD
RANDALLSTOWN MD
21133-4655
US

V. Phone/Fax

Practice location:
  • Phone: 410-922-2617
  • Fax: 410-922-4620
Mailing address:
  • Phone: 410-922-2617
  • Fax: 410-922-2462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number03AL1070-A
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number03AL1070-A
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number03AL1070-A
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number03AL1070-A
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number03AL1070-A
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number03AL1070-A
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number03AL1070-A
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number03AL1070-A
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number03AL1070-A
License Number StateMD
# 10
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number03AL1070-A
License Number StateMD
# 11
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number03AL1070-A
License Number StateMD
# 12
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number03AL1070-A
License Number StateMD
# 13
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number03AL1070-A
License Number StateMD

VIII. Authorized Official

Name: MS. GLORIA LYNN BROWN - BRISTOL
Title or Position: FOUNDER CEO/ EXCUTIVE OFFICER
Credential:
Phone: 410-922-2617