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
NCMHL 026 655320600000X
NCMHL 026 654320600000X
103TC0700X, 320800000X
NCFCL 026 026320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness