Provider Demographics
NPI:1023399292
Name:CHAVIS MANOR, LLC
Entity Type:Organization
Organization Name:CHAVIS MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:MILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-437-5873
Mailing Address - Street 1:204 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27249-2310
Mailing Address - Country:US
Mailing Address - Phone:336-437-5873
Mailing Address - Fax:
Practice Address - Street 1:204 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:GIBSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27249-2310
Practice Address - Country:US
Practice Address - Phone:336-437-5873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL041-10223104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness