Healthcare Provider Details

I. General information

NPI: 1427114420
Provider Name (Legal Business Name): CAPE FEAR MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 S. SMITH ST.
CLARKTON NC
28433
US

IV. Provider business mailing address

PO BOX 489
CLARKTON NC
28433-0489
US

V. Phone/Fax

Practice location:
  • Phone: 910-647-0509
  • Fax:
Mailing address:
  • Phone: 910-647-0509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL-009-001
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberHAL-009-001
License Number StateNC

VIII. Authorized Official

Name: RON DANELLA
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-647-0509