Basic Information
| Provider Information | |||||||||
| NPI: | 1275672693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLENCARE ASSISTED LIVING, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GLENCRE OF KINSTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 339 | ||||||||
| Address2: | |||||||||
| City: | KENANSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283490339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102750058 | ||||||||
| FaxNumber: | 9102750093 | ||||||||
| Practice Location | |||||||||
| Address1: | 1935 IDLEWILD DR | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285047148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522087104 | ||||||||
| FaxNumber: | 2522087105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KORNEGAY | ||||||||
| AuthorizedOfficialFirstName: | MARIAN | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9102750058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.N. HNA V.P. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL 054057 | NC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 7805698 | 05 | NY | MEDICAID |