Provider Demographics
NPI:1265441653
Name:EVERGREENE PROPERTIES OF NORTH CAROLINA,LLC
Entity Type:Organization
Organization Name:EVERGREENE PROPERTIES OF NORTH CAROLINA,LLC
Other - Org Name:CRESTPARK INN OF STUTTGART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-668-3896
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:STUTTGART
Mailing Address - State:AR
Mailing Address - Zip Code:72160-0790
Mailing Address - Country:US
Mailing Address - Phone:870-673-1657
Mailing Address - Fax:870-672-9751
Practice Address - Street 1:707 W 20TH ST
Practice Address - Street 2:
Practice Address - City:STUTTGART
Practice Address - State:AR
Practice Address - Zip Code:72160-6500
Practice Address - Country:US
Practice Address - Phone:870-673-1657
Practice Address - Fax:870-672-9751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR635314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119640311Medicaid
AR015303OtherBCBS PROVIDER NUMBER
AR045303Medicare ID - Type UnspecifiedPROVIDER NUMBER