Basic Information
| Provider Information | |||||||||
| NPI: | 1811906134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREENE PROPERTIES OF NORTH CAROLINA, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CRESTPARK INN OF WYNNE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1127 | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723961127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702387941 | ||||||||
| FaxNumber: | 8702381989 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 ARKANSAS AVE E | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723963407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702387941 | ||||||||
| FaxNumber: | 8702381989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREENE | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3366683896 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 636 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 015166 | 01 | AR | BCBS PROVIDER NUMBER | OTHER |