Provider Demographics
NPI:1184765406
Name:THELMAS RESIDENTIAL FACILITY
Entity type:Organization
Organization Name:THELMAS RESIDENTIAL FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKETHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-483-6584
Mailing Address - Street 1:1923 SIMON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-5381
Mailing Address - Country:US
Mailing Address - Phone:910-483-6584
Mailing Address - Fax:
Practice Address - Street 1:1923 SIMON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-5381
Practice Address - Country:US
Practice Address - Phone:910-483-6584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-790320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities