Healthcare Provider Details

I. General information

NPI: 1700323557
Provider Name (Legal Business Name): GREENVILLE HEALTH CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 MOSELEY DR
GREENVILLE NC
27858-4245
US

IV. Provider business mailing address

3121 MOSELEY DR
GREENVILLE NC
27858-4245
US

V. Phone/Fax

Practice location:
  • Phone: 252-758-4455
  • Fax: 252-758-6742
Mailing address:
  • Phone: 252-758-4455
  • Fax: 252-758-6742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number31627
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103099
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number100083
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200996
License Number StateNC

VIII. Authorized Official

Name: MR. C LEE QUINN JR.
Title or Position: PRESIDENT
Credential: PA
Phone: 252-758-4455