Provider Demographics
NPI:1275672693
Name:GLENCARE ASSISTED LIVING, INC
Entity Type:Organization
Organization Name:GLENCARE ASSISTED LIVING, INC
Other - Org Name:GLENCRE OF KINSTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN HNA VP
Authorized Official - Phone:910-275-0058
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-0339
Mailing Address - Country:US
Mailing Address - Phone:910-275-0058
Mailing Address - Fax:910-275-0093
Practice Address - Street 1:1935 IDLEWILD DR
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-7148
Practice Address - Country:US
Practice Address - Phone:252-208-7104
Practice Address - Fax:252-208-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL 054057310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7805698Medicaid
NC=========OtherTAX ID NUMBER