Provider Demographics
NPI:1942369079
Name:EXCEL FOR LIFE, LLC (CHERRYRUN HOME)
Entity Type:Organization
Organization Name:EXCEL FOR LIFE, LLC (CHERRYRUN HOME)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:JERMAINE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRIMINAL JUSTICE
Authorized Official - Phone:252-205-0381
Mailing Address - Street 1:2310 CHERRY RUN RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-8366
Mailing Address - Country:US
Mailing Address - Phone:252-946-8069
Mailing Address - Fax:252-205-0381
Practice Address - Street 1:2310 CHERRY RUN RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-8366
Practice Address - Country:US
Practice Address - Phone:252-946-8069
Practice Address - Fax:252-205-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC007052320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities