Provider Demographics
NPI:1407208168
Name:SERENITY MANOR @GWYNN OAK CORP
Entity Type:Organization
Organization Name:SERENITY MANOR @GWYNN OAK CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-801-3134
Mailing Address - Street 1:5216 GWYNN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6807
Mailing Address - Country:US
Mailing Address - Phone:443-801-3134
Mailing Address - Fax:
Practice Address - Street 1:5216 GWYNN OAK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-6807
Practice Address - Country:US
Practice Address - Phone:443-801-3134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30AL3565A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1467589242Medicaid
MD5795420101Medicaid