Provider Demographics
NPI:1962566182
Name:MARC'S MANOR LLC
Entity type:Organization
Organization Name:MARC'S MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-273-5838
Mailing Address - Street 1:3020 BROOKCROSSING DR
Mailing Address - Street 2:VILLAGE AT LAKEWOOD
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-9790
Mailing Address - Country:US
Mailing Address - Phone:910-273-5838
Mailing Address - Fax:
Practice Address - Street 1:3207 REMINISCE RD
Practice Address - Street 2:
Practice Address - City:CASTLE HAYNE
Practice Address - State:NC
Practice Address - Zip Code:28429
Practice Address - Country:US
Practice Address - Phone:910-675-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL065165322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children