=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124234166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENE HAVEN FAMILY CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 09/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1833 STONY POINT RD
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-487-0063
-----------------------------------------------------
Fax | 704-482-8001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1833 STONY POINT RD
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-487-0063
-----------------------------------------------------
Fax | 704-482-8001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. LATARSHA ROSEBORO GULLATTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-487-0063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | FCL-023-009
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------