Provider Demographics
NPI:1033204300
Name:MISS DAISY'S GENTLEMEN OF THE FUTURE INC.
Entity Type:Organization
Organization Name:MISS DAISY'S GENTLEMEN OF THE FUTURE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/QUALIFIED PROFESSIONAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:FULLER
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-363-5446
Mailing Address - Street 1:304 FAIRVIEW AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4817
Mailing Address - Country:US
Mailing Address - Phone:252-293-4683
Mailing Address - Fax:252-291-6962
Practice Address - Street 1:304 FAIRVIEW AVE SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4817
Practice Address - Country:US
Practice Address - Phone:252-293-4683
Practice Address - Fax:252-291-6962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL098100320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603888Medicaid