Provider Demographics
NPI:1760854715
Name:MOUNT EAGLE HEALTH CARE GREENSBORO, LLC
Entity Type:Organization
Organization Name:MOUNT EAGLE HEALTH CARE GREENSBORO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALLUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-283-5191
Mailing Address - Street 1:1 CENTERVIEW DR STE 203B
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3712
Mailing Address - Country:US
Mailing Address - Phone:336-283-5191
Mailing Address - Fax:336-499-6532
Practice Address - Street 1:6000 MUSEUM DR BLDG A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-9503
Practice Address - Country:US
Practice Address - Phone:336-283-5191
Practice Address - Fax:336-499-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2369251F00000X, 251J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251F00000XAgenciesHome Infusion
No253Z00000XAgenciesIn Home Supportive Care