MEDICARE: GREENE HAVEN FAMILY CARE HOME

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	310400000X	Assisted Living Facility
2	311ZA0620X	Adult Care Home Facility	FCL-023-009	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124234166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENE HAVEN FAMILY CARE HOME

Provider Business Mailing Address
First Line	:	1833 STONY POINT RD
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150-9601
Country	:	US
Telephone Number	:	704-487-0063
Fax Number	:	704-482-8001

Provider Business Practice Location Address
First Line	:	1833 STONY POINT RD
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150-9601
Country	:	US
Telephone Number	:	704-487-0063
Fax Number	:	704-482-8001

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LATARSHA ROSEBORO GULLATTE
Credential	:
Telephone Number	:	704-487-0063

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	09/24/2007

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Directions to “GREENE HAVEN FAMILY CARE HOME ” Practice Location

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