Healthcare Provider Details

I. General information

NPI: 1366091738
Provider Name (Legal Business Name): GREEN RIVER AREA DOWN SYNDROME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7155 MASONVILLE HABIT RD
PHILPOT KY
42366-9116
US

IV. Provider business mailing address

PO BOX 2031
OWENSBORO KY
42302-2031
US

V. Phone/Fax

Practice location:
  • Phone: 479-223-1234
  • Fax:
Mailing address:
  • Phone: 270-681-5313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY THRASH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 479-223-1234