Healthcare Provider Details

I. General information

NPI: 1376006130
Provider Name (Legal Business Name): GREEN BERET HEALTHCARE AGENCY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 HARVEST GROVE CT
HOPE MILLS NC
28348-9272
US

IV. Provider business mailing address

1014 HARVEST GROVE CT
HOPE MILLS NC
28348-9272
US

V. Phone/Fax

Practice location:
  • Phone: 910-364-5219
  • Fax: 866-704-9129
Mailing address:
  • Phone: 910-364-5219
  • Fax: 866-704-9129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: TIMMY MACK
Title or Position: DIRECTOR
Credential:
Phone: 910-364-5219