Evergreene Properties of North Carolina, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

636 Issued in AR

Legal business name

EVERGREENE PROPERTIES OF NORTH CAROLINA, LLC

Doing business as

Crestpark Inn of Wynne

Practice address

400 Arkansas Ave E
Wynne, AR 72396-3407

Phone

(870) 238-7941

Fax

(870) 238-1989

NPI assigned

Aug 5, 2006

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Daniel C Greene

Title

Manager

Phone

(336) 668-3896

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• CRESTPARK INN OF WYNNE Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154736000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1811906134",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1127",
            "city": "WYNNE",
            "state": "AR",
            "postal_code": "723961127",
            "telephone_number": "870-238-7941",
            "fax_number": "870-238-1989"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 ARKANSAS AVE E",
            "city": "WYNNE",
            "state": "AR",
            "postal_code": "723963407",
            "telephone_number": "870-238-7941",
            "fax_number": "870-238-1989"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREENE PROPERTIES OF NORTH CAROLINA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-05",
        "last_updated": "2020-08-22",
        "status": "A",
        "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",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "AR",
            "license": "636",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PROVIDER NUMBER",
            "identifier": "015166",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CRESTPARK INN OF WYNNE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Anna Lilly Eaton
• Broderick Eaton, DO
• William David Eidt, LPC
• Lisa Ellis, PTA
• Kristina R Eppes, RPH
• Lisa G Fancher, PD
• Taylor Brianne Fitts, PTA
• Jamie Foster, OTA
• Jennifer Foust
• Jamie L Frederick, MCD, CCC-SLP

• Skilled Nursing Facility in Wynne, AR
• Providers in Wynne, AR by specialty
• Skilled Nursing Facility in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.