MEDICARE: CYPRESS GLEN RETIREMENT COMMUNITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	NH0473	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	009CH	OTHER	NC	BLIE CROSS AND BLUE SHILE

General Provider Information

NPI Number	:	1053395335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CYPRESS GLEN RETIREMENT COMMUNITY

Provider Business Mailing Address
First Line	:	100 HICKORY STREET
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27585-1637
Country	:	US
Telephone Number	:	252-830-0036
Fax Number	:	252-830-0411

Provider Business Practice Location Address
First Line	:	100 HICKORY STREET
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27585-1637
Country	:	US
Telephone Number	:	252-830-0036
Fax Number	:	252-830-0411

Authorized Official
Title or Position	:	CHAIRMAN OF THE BOARD
Name	:	MR. DONALD E. METZGER SR.
Credential	:
Telephone Number	:	910-738-4652

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	08/11/2011

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Directions to “CYPRESS GLEN RETIREMENT COMMUNITY ” Practice Location

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