Provider Demographics
NPI:1952636649
Name:PEACE & GLORY MANOR,INC
Entity Type:Organization
Organization Name:PEACE & GLORY MANOR,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER CEO, PRESIDENT
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:410-922-4620
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:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 310400000X, 3104A0625X, 3104A0630X, 314000000X, 343900000X, 347C00000X
MD302R00000X, 347B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251B00000XAgenciesCase Management
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347B00000XTransportation ServicesBus
No347C00000XTransportation ServicesPrivate Vehicle