Provider Demographics
NPI:1083753073
Name:SOUTH POINT MANOR
Entity Type:Organization
Organization Name:SOUTH POINT MANOR
Other - Org Name:SOUTH POINT MANOR INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SENORA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-639-6893
Mailing Address - Street 1:2316 ANGIER RD
Mailing Address - Street 2:3218 HWY 55
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526
Mailing Address - Country:US
Mailing Address - Phone:919-639-6893
Mailing Address - Fax:919-639-2913
Practice Address - Street 1:3218 HWY 55
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713
Practice Address - Country:US
Practice Address - Phone:919-361-0721
Practice Address - Fax:919-544-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL032072320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804941Medicaid