Provider Demographics
NPI:1104936103
Name:GRACESON MANOR
Entity type:Organization
Organization Name:GRACESON MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GWYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-349-3610
Mailing Address - Street 1:116 GWYNN DR
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-8710
Mailing Address - Country:US
Mailing Address - Phone:336-349-2806
Mailing Address - Fax:
Practice Address - Street 1:116 GWYNN DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8710
Practice Address - Country:US
Practice Address - Phone:336-349-2806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-079-054310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805575OtherEDS NUMBER