Organization
MISS DAISY'S GENTLEMEN OF THE FUTURE INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TONYA FULLER JOHNSON (DIRECTOR/QUALIFIED PROFESSIONAL)
(252) 363-5446
Entity
Organization
Contact information
Practice address
304 FAIRVIEW AVE SW, WILSON, NC 27893-4817
(252) 293-4683
(252) 291-6962
Mailing address
304 FAIRVIEW AVE SW, WILSON, NC 27893-4817
(252) 293-4683
(252) 291-6962
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
MHL098100
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6603888
—
NC
Enumeration date
10/04/2006
Last updated
08/22/2020
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