Provider Demographics
NPI:1053908053
Name:PRIDE ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:PRIDE ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:IESHIA
Authorized Official - Middle Name:LATOYA
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-814-7882
Mailing Address - Street 1:1003 WHATCOAT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-2220
Mailing Address - Country:US
Mailing Address - Phone:443-708-3017
Mailing Address - Fax:
Practice Address - Street 1:1003 WHATCOAT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-2220
Practice Address - Country:US
Practice Address - Phone:443-708-3017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility