Healthcare Provider Details

I. General information

NPI: 1356383236
Provider Name (Legal Business Name): GREEN RIVER REGIONAL MENTAL HEALTH/MENTAL RETARDATION BOARD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 RUDY RD
OWENSBORO KY
42301-9562
US

IV. Provider business mailing address

PO BOX 1637
OWENSBORO KY
42302-1637
US

V. Phone/Fax

Practice location:
  • Phone: 270-691-0786
  • Fax:
Mailing address:
  • Phone: 270-691-0786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number950012
License Number StateKY

VIII. Authorized Official

Name: J. MICHAEL MOUNTAIN
Title or Position: CFO
Credential:
Phone: 270-689-6500