Provider Demographics
NPI:1821124116
Name:GRACELAND MANOR & ASSOCIATES, INC
Entity Type:Organization
Organization Name:GRACELAND MANOR & ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELVA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-488-8807
Mailing Address - Street 1:PO BOX 35174
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-0174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:408 PELT DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3412
Practice Address - Country:US
Practice Address - Phone:910-322-6855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X, 320800000X
NCMHL 026 655320600000X
NCMHL 026 654320600000X
NCFCL 026 026320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness