MEDICARE: FB PEYTON ROCK OF AGING,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	251J00000X	Nursing Care Agency	081001	MD
2	251E00000X	Home Health Agency	0810001	MD

General Provider Information

NPI Number	:	1861638470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FB PEYTON ROCK OF AGING,LLC

Provider Business Mailing Address
First Line	:	1421 CLARKVIEW RD
Second Line	:	SUITE 100B
City	:	BALTIMORE
State	:	MD
Zip	:	21209-2133
Country	:	US
Telephone Number	:	410-583-1944
Fax Number	:	410-583-1966

Provider Business Practice Location Address
First Line	:	1421 CLARKVIEW RD
Second Line	:	SUITE 100B
City	:	BALTIMORE
State	:	MD
Zip	:	21209-2133
Country	:	US
Telephone Number	:	410-583-1944
Fax Number	:	410-583-1966

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	FBRADLEY PEYTON
Credential	:	J.D., M.DIV.
Telephone Number	:	410-583-1944

Provider Enumeration Date	:	01/02/2009
Last Update Date	:	01/02/2009

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