Provider Demographics
NPI:1487663449
Name:EVERGREENE PPROPERTIES OF NORTH CAROLINA,LLC
Entity Type:Organization
Organization Name:EVERGREENE PPROPERTIES OF NORTH CAROLINA,LLC
Other - Org Name:CRESTPARK OF MARIANNA
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 386
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-0386
Mailing Address - Country:US
Mailing Address - Phone:870-295-3466
Mailing Address - Fax:870-295-5474
Practice Address - Street 1:700 WEST CHESTNUT HWY 79 WEST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360-0386
Practice Address - Country:US
Practice Address - Phone:870-295-3466
Practice Address - Fax:870-295-5474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR634314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility