MEDICARE: SERENITY MANOR @GWYNN OAK CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	30AL3565A	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407208168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERENITY MANOR @GWYNN OAK CORP

Provider Business Mailing Address
First Line	:	5216 GWYNN OAK AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-6807
Country	:	US
Telephone Number	:	443-801-3134
Fax Number	:

Provider Business Practice Location Address
First Line	:	5216 GWYNN OAK AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-6807
Country	:	US
Telephone Number	:	443-801-3134
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CAMILLE MATTHEWS
Credential	:
Telephone Number	:	443-801-3134

Provider Enumeration Date	:	07/06/2016
Last Update Date	:	07/06/2016

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