MEDICARE: CLUB GREEN CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	174200000X	Meals Provider
2	251C00000X	Developmentally Disabled Services Day Training Agency
3	253Z00000X	In Home Supportive Care Agency
4	261QA0600X	Adult Day Care Clinic/Center
5	332U00000X	Home Delivered Meals
6	343900000X	Non-emergency Medical Transport (VAN)
7	376J00000X	Homemaker
8	347C00000X	Private Vehicle
9	385H00000X	Respite Care
10	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
11	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1639940547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLUB GREEN CORPORATION

Provider Business Mailing Address
First Line	:	1096 MERCER AVE
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44320-3646
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3602 MOBILE CT
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-4206
Country	:	US
Telephone Number	:	330-803-5644
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	NADIR HAZLY
Credential	:
Telephone Number	:	214-701-7227

Provider Enumeration Date	:	01/10/2024
Last Update Date	:	03/31/2024

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Directions to “CLUB GREEN CORPORATION ” Practice Location

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