Provider Demographics
NPI:1255571766
Name:FAYETTEVILLE MANOR, LLC
Entity type:Organization
Organization Name:FAYETTEVILLE MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSVAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-608-0761
Mailing Address - Street 1:PO BOX 9895
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9093
Mailing Address - Country:US
Mailing Address - Phone:910-488-4821
Mailing Address - Fax:910-488-5069
Practice Address - Street 1:231 TREETOP DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-0606
Practice Address - Country:US
Practice Address - Phone:910-488-4821
Practice Address - Fax:910-488-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-026-054310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility