Basic Information
| Provider Information | |||||||||
| NPI: | 1629136197 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KORNEGAY HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GLENCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 214 LANEFIELD RD | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283988719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102933144 | ||||||||
| FaxNumber: | 9102934424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KORNEGAY | ||||||||
| AuthorizedOfficialFirstName: | MARIAN | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9102750058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NHO418 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3485252 | 05 | NC | MEDICAID | 3455252 | 05 | NC | MEDICAID | 3436396 | 05 | NC | MEDICAID |