Healthcare Provider Details

I. General information

NPI: 1528454683
Provider Name (Legal Business Name): GREENVILLE AS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 KENNETT PIKE E126
WILMINGTON DE
19807-2321
US

IV. Provider business mailing address

1000 FIRST AVE STE 100
KING OF PRUSSIA PA
19406-1333
US

V. Phone/Fax

Practice location:
  • Phone: 610-337-7662
  • Fax:
Mailing address:
  • Phone: 610-337-7662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN CAMPBELL
Title or Position: OWNER
Credential:
Phone: 610-337-7662