Healthcare Provider Details

I. General information

NPI: 1114106077
Provider Name (Legal Business Name): MARION E. WALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 STAMPER RD
FAYETTEVILLE NC
28303-4138
US

IV. Provider business mailing address

920 STAMPER RD
FAYETTEVILLE NC
28303-4138
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-4424
  • Fax: 910-323-3622
Mailing address:
  • Phone: 910-323-4424
  • Fax: 910-323-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARION ELIZABETH WALL
Title or Position: DIRECTOR/OWNER
Credential:
Phone: 910-323-4424