Provider Demographics
NPI:1699914283
Name:CHESTNUT MANOR MANGUM STREET
Entity type:Organization
Organization Name:CHESTNUT MANOR MANGUM STREET
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:CHESTNUT
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-638-6174
Mailing Address - Street 1:830 N MANGUM ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-2259
Mailing Address - Country:US
Mailing Address - Phone:919-688-6923
Mailing Address - Fax:
Practice Address - Street 1:830 N MANGUM ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2259
Practice Address - Country:US
Practice Address - Phone:919-688-6923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTNUT MANOR INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-032-092310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility