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General NPI Number Information
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NPI Number | 1255571766
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Entity Type | Organization
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Legal Business Name | FAYETTEVILLE MANOR, LLC
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Dates
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Enumeration Date | 02/23/2009
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Last Update Date | 02/23/2009
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Provider Practice Location Address
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Address Line | 231 TREETOP DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28311-0606
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Country | US
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Telephone | 910-488-4821
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Fax | 910-488-5069
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Provider Business Mailing Address
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Address Line | PO BOX 9895
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City | FAYETTEVILLE
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State | NC
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Zip | 28311-9093
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Country | US
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Telephone | 910-488-4821
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Fax | 910-488-5069
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Authorized Official
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Title or Position | MEMBER
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Name | MR. THOMAS HUSVAR
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Credential |
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Telephone | 704-608-0761
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | HAL-026-054
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License Number State | NC
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