MEDICARE: GRAY MANOR ASSISTED LIVING LLC

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

General Provider Information

NPI Number	:	1659060846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAY MANOR ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	3707 WOODBINE AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-7144
Country	:	US
Telephone Number	:	443-423-3188
Fax Number	:

Provider Business Practice Location Address
First Line	:	3707 WOODBINE AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-7144
Country	:	US
Telephone Number	:	443-423-3188
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DANIELLE DODD
Credential	:
Telephone Number	:	443-423-3188

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	05/03/2023

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