Provider Demographics
NPI:1558547315
Name:EXCEL FOR LIFE (CEDAR HOME)
Entity Type:Organization
Organization Name:EXCEL FOR LIFE (CEDAR HOME)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:JERMAINE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELORS CRIMINAL
Authorized Official - Phone:252-205-0381
Mailing Address - Street 1:108 CEDAR CIR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-9506
Mailing Address - Country:US
Mailing Address - Phone:252-946-1432
Mailing Address - Fax:
Practice Address - Street 1:108 CEDAR CIR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-9506
Practice Address - Country:US
Practice Address - Phone:252-946-1432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children