Healthcare Provider Details

I. General information

NPI: 1366624371
Provider Name (Legal Business Name): GLENCARE OF BLADENBORO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 EAST BLADEN STREET
BLADENBORO NC
28320
US

IV. Provider business mailing address

PO BOX 339
KENANSVILLE NC
28349-0339
US

V. Phone/Fax

Practice location:
  • Phone: 910-863-4500
  • Fax: 910-863-3142
Mailing address:
  • Phone: 910-275-0058
  • Fax: 910-275-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MARIAN ANNE KORNEGAY
Title or Position: VICE PRESIDENT
Credential:
Phone: 910-275-0058