=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700323557
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREENVILLE HEALTH CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2017
-----------------------------------------------------
Last Update Date | 01/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3121 MOSELEY DR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-4245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-758-4455
-----------------------------------------------------
Fax | 252-758-6742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3121 MOSELEY DR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-4245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-758-4455
-----------------------------------------------------
Fax | 252-758-6742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. C LEE QUINN JR.
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 252-758-4455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 103099
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 100083
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 200996
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 31627
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------