Healthcare Provider Details

I. General information

NPI: 1992714992
Provider Name (Legal Business Name): EVERGREENE PROPERTIES OF NORTH CAROLINA,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LIBERTY DRIVE
DEWITT AR
72042-0589
US

IV. Provider business mailing address

PO BOX 589
DEWITT AR
72042-0589
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-3569
  • Fax: 870-946-0699
Mailing address:
  • Phone: 870-946-3569
  • Fax: 870-946-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number637
License Number StateAR

VIII. Authorized Official

Name: MR. DANIEL C GREENE
Title or Position: MANAGER
Credential:
Phone: 336-668-3896