Provider Demographics
NPI: | 1821324849 |
---|---|
Name: | PEACE & GLORY MANOR, LLC |
Entity Type: | Organization |
Organization Name: | PEACE & GLORY MANOR, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | FOUNDER CEO/ EXCUTIVE OFFICER |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | GLORIA |
Authorized Official - Middle Name: | LYNN |
Authorized Official - Last Name: | BROWN - BRISTOL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 410-922-2617 |
Mailing Address - Street 1: | 3829 KILBURN RD |
Mailing Address - Street 2: | |
Mailing Address - City: | RANDALLSTOWN |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21133-4655 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 410-922-2617 |
Mailing Address - Fax: | 410-922-2462 |
Practice Address - Street 1: | 3829 KILBURN RD |
Practice Address - Street 2: | |
Practice Address - City: | RANDALLSTOWN |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21133-4655 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-922-2617 |
Practice Address - Fax: | 410-922-4620 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-10-27 |
Last Update Date: | 2009-10-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | 03AL1070-A | 101YA0400X, 133N00000X, 133NN1002X, 133VN1005X, 136A00000X, 163W00000X, 163WA0400X, 163WA2000X, 163WC0400X, 163WC1600X, 163WD0400X, 310400000X, 3104A0630X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | ||
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
No | 133NN1002X | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | Group - Multi-Specialty |
No | 133VN1005X | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Renal | Group - Multi-Specialty |
No | 136A00000X | Dietary & Nutritional Service Providers | Dietetic Technician, Registered | Group - Multi-Specialty | |
No | 163W00000X | Nursing Service Providers | Registered Nurse | Group - Multi-Specialty | |
No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 163WA2000X | Nursing Service Providers | Registered Nurse | Administrator | Group - Multi-Specialty |
No | 163WC0400X | Nursing Service Providers | Registered Nurse | Case Management | Group - Multi-Specialty |
No | 163WC1600X | Nursing Service Providers | Registered Nurse | Continuing Education/Staff Development | Group - Multi-Specialty |
No | 163WD0400X | Nursing Service Providers | Registered Nurse | Diabetes Educator | Group - Multi-Specialty |
No | 3104A0630X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances |