MEDICARE: LIFETIME SERENITY 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	30AL3431-A	MD

General Provider Information

NPI Number	:	1669919387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETIME SERENITY ASSISTED LIVING

Provider Business Mailing Address
First Line	:	3304 MENLO DR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-3826
Country	:	US
Telephone Number	:	410-358-4401
Fax Number	:	410-358-4402

Provider Business Practice Location Address
First Line	:	8507 LIBERTY RD
Second Line	:
City	:	RANDALLSTOWN
State	:	MD
Zip	:	21133-4833
Country	:	US
Telephone Number	:	410-496-9105
Fax Number	:	410-496-9109

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. DONOVAN PARKES
Credential	:	MD
Telephone Number	:	410-428-1382

Provider Enumeration Date	:	01/20/2017
Last Update Date	:	01/20/2017

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