1669613071 NPI number — GREATEST GENERATION, INC.

Table of content: (NPI 1669613071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669613071 NPI number — GREATEST GENERATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATEST GENERATION, INC.
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:
THE SHANNON GRAY REHABILITATION & RECOVERY CENTER
Provider Other Organization Name Type Code:
3
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:
1669613071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 LANE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRINITY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27370-9343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-431-8888
Provider Business Mailing Address Fax Number:
336-431-9064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2005 SHANNON GRAY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27282-9183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-307-4729
Provider Business Practice Location Address Fax Number:
336-307-4961
Provider Enumeration Date:
03/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
GRAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-253-6491

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3405552 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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