Basic Information
| Provider Information | |||||||||
| NPI: | 1295864452 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOE RIVER HEALTH DISTRICT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 861 GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SPRUCE PINE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287773113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287652239 | ||||||||
| FaxNumber: | 8287659082 | ||||||||
| Practice Location | |||||||||
| Address1: | 861 GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SPRUCE PINE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287773113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287652239 | ||||||||
| FaxNumber: | 8287659082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 01/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | GREENE | ||||||||
| AuthorizedOfficialFirstName: | JESSE | ||||||||
| AuthorizedOfficialMiddleName: | EARL | ||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH DIRCTOR | ||||||||
| AuthorizedOfficialTelephone: | 8287652239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QP0905X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local |
ID Information
| ID | Type | State | Issuer | Description | 3404484 | 05 | NC | MEDICAID | 3404300 | 05 | NC | MEDICAID | 3404306 | 05 | NC | MEDICAID | 3404361 | 05 | NC | MEDICAID | 34D0865328 | 01 | NC | CLIA LICENCE # | OTHER |