MEDICARE: EVERGREENE PROPERTIES OF NORTH CAROLINA,LLC

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	639	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	015349	OTHER	AR	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1457361974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREENE PROPERTIES OF NORTH CAROLINA,LLC

Provider Business Mailing Address
First Line	:	PO BOX 310
Second Line	:
City	:	HELENA
State	:	AR
Zip	:	72342-0310
Country	:	US
Telephone Number	:	870-338-3405
Fax Number	:	870-338-3499

Provider Business Practice Location Address
First Line	:	110 HOSPITAL DR
Second Line	:
City	:	HELENA
State	:	AR
Zip	:	72342-1507
Country	:	US
Telephone Number	:	870-338-3405
Fax Number	:	870-338-3499

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. DANIEL C GREENE
Credential	:
Telephone Number	:	336-668-3896

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	08/22/2020

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