Healthcare Provider Details

I. General information

NPI: 1023344066
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: 410-922-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number03AL1070-A
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number03AL1070-A
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number03AL1070-A
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number03AL1070-A
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number03AL1070-A
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number03AL1070-A
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number03AL1070-A
License Number StateMD
# 8
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number03AL1070-A
License Number StateMD

VIII. Authorized Official

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