MEDICARE: MARLEA MANOR ASSISTED LIVING

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	30AL1440	MD

General Provider Information

NPI Number	:	1609072735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARLEA MANOR ASSISTED LIVING

Provider Business Mailing Address
First Line	:	11106 TOWOOD RD
Second Line	:
City	:	KINGSVILLE
State	:	MD
Zip	:	21087-1738
Country	:	US
Telephone Number	:	410-592-8418
Fax Number	:	410-592-3233

Provider Business Practice Location Address
First Line	:	4405 RASPE AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21206-1926
Country	:	US
Telephone Number	:	410-488-3135
Fax Number	:	410-488-3135

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WILLIAM BRIAN KING
Credential	:
Telephone Number	:	410-592-8418

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/24/2008

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