Provider Demographics
NPI:1871722637
Name:INGRAM HEALTH SERVICES/MANNA HOUSE,INC
Entity type:Organization
Organization Name:INGRAM HEALTH SERVICES/MANNA HOUSE,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-318-3946
Mailing Address - Street 1:675 NC HWY 71 N
Mailing Address - Street 2:
Mailing Address - City:MAXTON
Mailing Address - State:NC
Mailing Address - Zip Code:28364
Mailing Address - Country:US
Mailing Address - Phone:910-844-6262
Mailing Address - Fax:910-844-6265
Practice Address - Street 1:505 WEST MARTIN LUTHER KING DRIVE
Practice Address - Street 2:
Practice Address - City:MAXTON
Practice Address - State:NC
Practice Address - Zip Code:28364
Practice Address - Country:US
Practice Address - Phone:910-844-6262
Practice Address - Fax:910-844-6265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301873Medicaid