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General NPI Number Information
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NPI Number | 1255774485
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Entity Type | Organization
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Legal Business Name | MARY REBECCA'S VILLAGE
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Dates
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Enumeration Date | 04/08/2013
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Last Update Date | 04/09/2013
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Provider Practice Location Address
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Address Line | 13605 US HIGHWAY 17 N
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City | HAMPSTEAD
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State | NC
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Zip | 28443-1945
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Country | US
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Telephone | 910-319-0450
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Fax |
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Provider Business Mailing Address
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Address Line | 1887 SPIRALWOOD DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28304-0499
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Country | US
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Telephone | 910-527-4673
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. CYNTHIA DANETTA GARRISON
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Credential |
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Telephone | 910-527-4673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | FCL-071-013
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License Number State | NC
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