Provider Demographics
NPI:1376006130
Name:GREEN BERET HEALTHCARE AGENCY, INC
Entity Type:Organization
Organization Name:GREEN BERET HEALTHCARE AGENCY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-364-5219
Mailing Address - Street 1:1014 HARVEST GROVE CT
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-9272
Mailing Address - Country:US
Mailing Address - Phone:910-364-5219
Mailing Address - Fax:866-704-9129
Practice Address - Street 1:1014 HARVEST GROVE CT
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-9272
Practice Address - Country:US
Practice Address - Phone:910-364-5219
Practice Address - Fax:866-704-9129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6602223Medicaid