Provider Demographics
NPI:1114644598
Name:MARYS HOUSE OF RESTORATION, INC.
Entity Type:Organization
Organization Name:MARYS HOUSE OF RESTORATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRANTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-744-8799
Mailing Address - Street 1:9320 CLOVERHILL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4617
Mailing Address - Country:US
Mailing Address - Phone:501-744-8799
Mailing Address - Fax:501-747-1149
Practice Address - Street 1:9320 CLOVERHILL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4617
Practice Address - Country:US
Practice Address - Phone:501-744-8799
Practice Address - Fax:501-747-1149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty