Healthcare Provider Details

I. General information

NPI: 1528641214
Provider Name (Legal Business Name): GREEN CROSS FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 E 30TH ST
INDIANAPOLIS IN
46205-3909
US

IV. Provider business mailing address

3421 LEE RD
SNELLVILLE GA
30039-5621
US

V. Phone/Fax

Practice location:
  • Phone: 317-641-2026
  • Fax:
Mailing address:
  • Phone: 317-641-2026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC0050X
TaxonomyCritical Access Hospital Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. CHUKWUUEMEKA CHIDEBELU-EZE
Title or Position: COFOUNDER
Credential: DC,MS
Phone: 404-671-9564