MEDICARE: CELEBRATE LIFE DAY CENTER, L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency		NC

General Provider Information

NPI Number	:	1144556887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CELEBRATE LIFE DAY CENTER, L.L.C.

Provider Business Mailing Address
First Line	:	204 LOVINGTON DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-2330
Country	:	US
Telephone Number	:	919-452-9324
Fax Number	:

Provider Business Practice Location Address
First Line	:	5869 YADKIN RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-2656
Country	:	US
Telephone Number	:	919-452-9324
Fax Number	:

Authorized Official
Title or Position	:	CEO/ADMINISTRATOR
Name	:	MR. MARCUS JERMAINE DAVIS
Credential	:
Telephone Number	:	919-452-9324

Provider Enumeration Date	:	10/31/2009
Last Update Date	:	10/31/2009

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