Healthcare Provider Details

I. General information

NPI: 1215207758
Provider Name (Legal Business Name): THE GREEN WAVE PROJECT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 STARK RD
WORCESTER MA
01602-4127
US

IV. Provider business mailing address

8 STARK RD
WORCESTER MA
01602-4127
US

V. Phone/Fax

Practice location:
  • Phone: 508-735-8044
  • Fax: 508-798-0867
Mailing address:
  • Phone: 508-735-8044
  • Fax: 508-798-0867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number3027345
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. ALLEN KNOLL
Title or Position: CEO
Credential:
Phone: 508-735-8044