Provider Demographics
| NPI: | 1104159839 |
|---|---|
| Name: | PEACE & GLORY MANOR, INC |
| Entity type: | Organization |
| Organization Name: | PEACE & GLORY MANOR, INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | OWNER |
| 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: | 443-386-9959 |
| 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: | 443-386-9959 |
| 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: | 443-389-9959 |
| Practice Address - Fax: | 410-922-4620 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2009-09-14 |
| Last Update Date: | 2009-09-14 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Single Specialty |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Single Specialty |
| No | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | Group - Single Specialty |
| No | 207ZB0001X | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | Group - Single Specialty |
| No | 208U00000X | Allopathic & Osteopathic Physicians | Clinical Pharmacology | Group - Single Specialty | |
| No | 251300000X | Agencies | Local Education Agency (LEA) | ||
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
| No | 251J00000X | Agencies | Nursing Care | ||
| No | 251V00000X | Agencies | Voluntary or Charitable | ||
| No | 261QE0700X | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment | |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
| No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | |
| No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | |
| No | 261QR0401X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
