Provider Demographics
NPI:1386044816
Name:HERTFORD MANOR
Entity Type:Organization
Organization Name:HERTFORD MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-402-5317
Mailing Address - Street 1:1220 PAMLICO ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3821
Mailing Address - Country:US
Mailing Address - Phone:252-402-5317
Mailing Address - Fax:
Practice Address - Street 1:464 TWO MILE DESERT RD
Practice Address - Street 2:
Practice Address - City:HERTFORD
Practice Address - State:NC
Practice Address - Zip Code:27944-8686
Practice Address - Country:US
Practice Address - Phone:252-402-5317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL072012311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home