Basic Information
Provider Information | |||||||||
NPI: | 1447326517 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOE RIVER HEALTH DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | YANCEY COUNTY HEALTH DEPT PERSONAL CARE SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 861 GREENWOOD RD | ||||||||
Address2: |   | ||||||||
City: | SPRUCE PINE | ||||||||
State: | NC | ||||||||
PostalCode: | 287773113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8287659081 | ||||||||
FaxNumber: | 8287659082 | ||||||||
Practice Location | |||||||||
Address1: | 200 MEDICAL CAMPUS DR | ||||||||
Address2: |   | ||||||||
City: | BURNSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 287149004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286827967 | ||||||||
FaxNumber: | 8286827584 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 02/02/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GREENE | ||||||||
AuthorizedOfficialFirstName: | JESSE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HEALTH DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8287659081 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747P1801X | HC0323 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Technician | Personal Care Attendant |
ID Information
ID | Type | State | Issuer | Description | 6600235 | 05 | NC |   | MEDICAID |