=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700906070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENN KRYSTLE MANOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 DAVIS ST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28305-5346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-486-8854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1887 SPIRALWOOD DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-0499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-527-4673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER ADMINISTRATOR
-----------------------------------------------------
Name | MS. CYNTHIA DANETTA GARRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-527-4673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | FCL-026-049
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------