Provider Demographics
NPI:1881891521
Name:ELY ENTERPRISES, INC.
Entity type:Organization
Organization Name:ELY ENTERPRISES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:DONNELL
Authorized Official - Last Name:ELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-683-6476
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-0274
Mailing Address - Country:US
Mailing Address - Phone:910-683-6476
Mailing Address - Fax:910-683-6476
Practice Address - Street 1:3999 FAYETTEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-0274
Practice Address - Country:US
Practice Address - Phone:910-683-6476
Practice Address - Fax:910-683-6476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-047-049320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418202Medicaid
NC7804458Medicaid