Healthcare Provider Details

I. General information

NPI: 1003149733
Provider Name (Legal Business Name): PEACE & GLORY MANOR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
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: 443-386-9959
  • Fax: 410-922-4620
Mailing address:
  • Phone: 443-386-9959
  • Fax: 410-922-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MS. GLORIA LYNN BROWN - BRISTOL
Title or Position: OWNER
Credential:
Phone: 443-386-9959