Healthcare Provider Details

I. General information

NPI: 1255574034
Provider Name (Legal Business Name): GREATER IMAGE HEALTHCARE, CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROBERSON STREET
FAYETTEVILLE NC
28301-5423
US

IV. Provider business mailing address

401 ROBERSON STREET
FAYETTEVILLE NC
28301-5423
US

V. Phone/Fax

Practice location:
  • Phone: 910-321-0069
  • Fax: 910-491-1000
Mailing address:
  • Phone: 910-321-0069
  • Fax: 910-491-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RODNEY JOHNSON
Title or Position: CEO
Credential:
Phone: 910-321-0069