Provider Demographics
NPI:1033404926
Name:MARIAN'S MANOR ASSISTED LIVING
Entity Type:Organization
Organization Name:MARIAN'S MANOR ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-205-7543
Mailing Address - Street 1:27 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1203
Mailing Address - Country:US
Mailing Address - Phone:443-205-7543
Mailing Address - Fax:410-768-3103
Practice Address - Street 1:27 OLD SOUTH RIVER RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1203
Practice Address - Country:US
Practice Address - Phone:443-205-7543
Practice Address - Fax:410-768-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-18
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02AL0318-A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility