Provider Demographics
NPI:1679612642
Name:GLENCARE ASSISTED LIVING, INC.
Entity Type:Organization
Organization Name:GLENCARE ASSISTED LIVING, INC.
Other - Org Name:GLENCARE OF HOLLY RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN NHA 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 1:3255 SOUND ROAD
Practice Address - Street 2:
Practice Address - City:HOLY RIDGE
Practice Address - State:NC
Practice Address - Zip Code:28445-0157
Practice Address - Country:US
Practice Address - Phone:910-329-9941
Practice Address - Fax:910-329-9943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL067015310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805699Medicaid
NC=========OtherTAX ID NUMBER