Provider Demographics
NPI:1437279551
Name:CHESTNUT MANOR
Entity Type:Organization
Organization Name:CHESTNUT MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRAOR
Authorized Official - Prefix:MS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:CHESTNUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-401-5781
Mailing Address - Street 1:2018 BIVINS ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-1404
Mailing Address - Country:US
Mailing Address - Phone:919-401-5781
Mailing Address - Fax:
Practice Address - Street 1:2018 BIVINS ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1404
Practice Address - Country:US
Practice Address - Phone:919-401-5781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC032339320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805149Medicaid