Provider Demographics
NPI:1669919387
Name:LIFETIME SERENITY ASSISTED LIVING
Entity type:Organization
Organization Name:LIFETIME SERENITY ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-428-1382
Mailing Address - Street 1:3304 MENLO DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3826
Mailing Address - Country:US
Mailing Address - Phone:410-358-4401
Mailing Address - Fax:410-358-4402
Practice Address - Street 1:8507 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4833
Practice Address - Country:US
Practice Address - Phone:410-496-9105
Practice Address - Fax:410-496-9109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30AL3431-A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility