Provider Demographics
NPI:1801960083
Name:GREENBRIER LTC INC
Entity type:Organization
Organization Name:GREENBRIER LTC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RILEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-648-6887
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:CLARKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28433
Mailing Address - Country:US
Mailing Address - Phone:910-648-6887
Mailing Address - Fax:910-648-6888
Practice Address - Street 1:703 SOUTH WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340
Practice Address - Country:US
Practice Address - Phone:910-628-9021
Practice Address - Fax:910-628-7441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL078053310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805461Medicaid