Provider Demographics
NPI:1558776948
Name:ANN'S COUNTRY MANOR
Entity Type:Organization
Organization Name:ANN'S COUNTRY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-790-7663
Mailing Address - Street 1:105 AVERY ST
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5312 SIX FORKS RD STE 301
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4458
Practice Address - Country:US
Practice Address - Phone:919-790-7663
Practice Address - Fax:919-790-6990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRANDELLS ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-25
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-861251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804626Medicaid