1023026135 NPI number — EVERGREENE PROPERTIES OF NORTH CAROLINA, LLC

Table of content: EDWARD MCGUIRL LCDP, RCS, CCJP (NPI 1356580716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023026135 NPI number — EVERGREENE PROPERTIES OF NORTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREENE PROPERTIES OF NORTH CAROLINA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023026135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORREST CITY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72336-1658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-633-4260
Provider Business Mailing Address Fax Number:
870-633-1486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 KITTLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORREST CITY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72335-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-633-4260
Provider Business Practice Location Address Fax Number:
870-633-1486
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREENE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
336-668-3896

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  638 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 015219 . This is a "MEDIPAK PROVIDER NUMBER" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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