Healthcare Provider Details

I. General information

NPI: 1326162363
Provider Name (Legal Business Name): MARY'S MANOR II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date: 06/03/2008
Reactivation Date: 07/09/2008

III. Provider practice location address

501 BUNN ST
ZEBULON NC
27597-9177
US

IV. Provider business mailing address

5641 QUAIL COVEY LANE
WENDELL NC
27591-7901
US

V. Phone/Fax

Practice location:
  • Phone: 919-796-5780
  • Fax: 919-266-7901
Mailing address:
  • Phone: 919-796-5780
  • Fax: 919-266-7901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberMHL 092 460
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL 092 460
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY LILLY MCCULLERS
Title or Position: OWNER ADMINISTRATOR
Credential:
Phone: 919-266-5291