Healthcare Provider Details

I. General information

NPI: 1073799003
Provider Name (Legal Business Name): NANCY GREEN INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 RUGBY RD
SALISBURY NC
28144-9489
US

IV. Provider business mailing address

P.O. BOX 1762
SALISBURY NC
28144-9489
US

V. Phone/Fax

Practice location:
  • Phone: 704-633-9747
  • Fax: 704-633-9608
Mailing address:
  • Phone: 704-633-9747
  • Fax: 704-633-9608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number175133
License Number StateNC

VIII. Authorized Official

Name: MRS. NANCY DESORMEAU GREEN
Title or Position: DIRECTOR
Credential: RN
Phone: 704-633-9747