Provider Demographics
NPI:1235480849
Name:DARRELLE E GREEN
Entity Type:Organization
Organization Name:DARRELLE E GREEN
Other - Org Name:GREEN MANOR REST HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRELLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-858-3826
Mailing Address - Street 1:PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:PARKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28371-0597
Mailing Address - Country:US
Mailing Address - Phone:910-858-3826
Mailing Address - Fax:910-858-3005
Practice Address - Street 1:1165 W PARKTON TOBEMORY RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:NC
Practice Address - Zip Code:28371-0299
Practice Address - Country:US
Practice Address - Phone:910-858-3826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-078-090310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility