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General NPI Number Information
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NPI Number | 1518976513
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Entity Type | Organization
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Legal Business Name | EVERGREENE PROPERTIES OF NORTH CAROLINA,LLC
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Dates
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Enumeration Date | 08/07/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 603 KITTLE ROAD
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City | FORREST CITY
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State | AR
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Zip | 72335-1033
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Country | US
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Telephone | 870-633-7630
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Fax | 870-633-6863
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Provider Business Mailing Address
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Address Line | PO BOX 1033
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City | FORREST CITY
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State | AR
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Zip | 72336-1033
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Country | US
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Telephone | 870-633-7630
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Fax | 870-633-6863
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Authorized Official
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Title or Position | MANAGER
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Name | MR. DANIEL C GREENE
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Credential |
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Telephone | 336-668-3896
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 632
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License Number State | AR
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