Healthcare Provider Details

I. General information

NPI: 1548230188
Provider Name (Legal Business Name): MASONIC AND EASTERN STAR HOME OF NORTH CAROLINA, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S HOLDEN RD
GREENSBORO NC
27407-2321
US

IV. Provider business mailing address

700 S HOLDEN RD
GREENSBORO NC
27407-2321
US

V. Phone/Fax

Practice location:
  • Phone: 336-299-0031
  • Fax: 336-547-2999
Mailing address:
  • Phone: 336-299-0031
  • Fax: 336-547-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH0141
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0141
License Number StateNC

VIII. Authorized Official

Name: MR. EUGENE JERNIGAN
Title or Position: CHAIRMAN, BOARD OF DIRECTORS
Credential:
Phone: 336-299-0031