Healthcare Provider Details

I. General information

NPI: 1003033085
Provider Name (Legal Business Name): GREEN RIVER AREA DEVELOPMENT DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 GRADD WAY
OWENSBORO KY
42301-8696
US

IV. Provider business mailing address

300 GRADD WAY
OWENSBORO KY
42301-8696
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-4433
  • Fax: 270-684-0714
Mailing address:
  • Phone: 270-926-4433
  • Fax: 270-684-0714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateKY

VIII. Authorized Official

Name: MR. JITEN SHAH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 270-926-4433