Provider Demographics
NPI:1992903926
Name:EVERETT FAMILY CARE HOME
Entity type:Organization
Organization Name:EVERETT FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNITH
Authorized Official - Middle Name:EDEN
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-345-1452
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:AULANDER
Mailing Address - State:NC
Mailing Address - Zip Code:27805
Mailing Address - Country:US
Mailing Address - Phone:252-345-1452
Mailing Address - Fax:252-345-1452
Practice Address - Street 1:402 BROAD ST
Practice Address - Street 2:
Practice Address - City:AULANDER
Practice Address - State:NC
Practice Address - Zip Code:27805
Practice Address - Country:US
Practice Address - Phone:252-345-1452
Practice Address - Fax:252-345-1452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFL008010311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803179Medicaid