=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376006130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN BERET HEALTHCARE AGENCY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2019
-----------------------------------------------------
Last Update Date | 04/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1014 HARVEST GROVE CT
-----------------------------------------------------
City | HOPE MILLS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28348-9272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-364-5219
-----------------------------------------------------
Fax | 866-704-9129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 HARVEST GROVE CT
-----------------------------------------------------
City | HOPE MILLS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28348-9272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-364-5219
-----------------------------------------------------
Fax | 866-704-9129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TIMMY MACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-364-5219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------