Provider Demographics
NPI:1871735233
Name:DFM INCORPORTATED ADOLESCENT HOME
Entity type:Organization
Organization Name:DFM INCORPORTATED ADOLESCENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:DELORSE
Authorized Official - Last Name:MONROE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:910-273-5473
Mailing Address - Street 1:7735 S SHIELD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-6352
Mailing Address - Country:US
Mailing Address - Phone:910-273-5473
Mailing Address - Fax:919-498-0874
Practice Address - Street 1:3999 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-8059
Practice Address - Country:US
Practice Address - Phone:910-273-5473
Practice Address - Fax:919-498-0874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-047-112320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities