Organization
SOUTHERN AVE REST HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. NEILL JONES (OWNER)
(910) 484-4291
Entity
Organization
Contact information
Practice address
1124 SOUTHERN AVE, FAYETTEVILLE, NC 28306-1754
(910) 286-8118
Mailing address
1124 SOUTHERN AVE, FAYETTEVILLE, NC 28306-1754
(910) 286-8118
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
FCL026012
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
78033383
—
NC
Enumeration date
12/20/2007
Last updated
12/20/2007
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