Provider Demographics
NPI:1205194701
Name:ELLIOTTE MANOR #1
Entity Type:Organization
Organization Name:ELLIOTTE MANOR #1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JUNIOUS
Authorized Official - Last Name:ELLIOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-545-3051
Mailing Address - Street 1:10201 CONNELL RD
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-6947
Mailing Address - Country:US
Mailing Address - Phone:704-545-1366
Mailing Address - Fax:704-545-3561
Practice Address - Street 1:10201 CONNELL RD
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-6947
Practice Address - Country:US
Practice Address - Phone:704-545-1366
Practice Address - Fax:704-545-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL060093310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility