Healthcare Provider Details

I. General information

NPI: 1992628630
Provider Name (Legal Business Name): GRAND CYPRESS COURT AFL HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4729 GRAND CYPRESS CT
RALEIGH NC
27604-5877
US

IV. Provider business mailing address

4729 GRAND CYPRESS CT
RALEIGH NC
27604-5877
US

V. Phone/Fax

Practice location:
  • Phone: 919-272-2594
  • Fax: 919-272-2594
Mailing address:
  • Phone: 919-272-2594
  • Fax: 919-272-2594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MISS HENRIETTA JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 919-272-2594