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General NPI Number Information
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NPI Number | 1821124116
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Entity Type | Organization
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Legal Business Name | GRACELAND MANOR & ASSOCIATES, INC
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 07/01/2010
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Provider Practice Location Address
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Address Line | 408 PELT DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28301-3412
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Country | US
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Telephone | 910-322-6855
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 35174
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-0174
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ELVA COLVIN
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Credential |
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Telephone | 910-488-8807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | MHL 026 655
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | MHL 026 654
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | FCL 026 026
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License Number State | NC
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