Healthcare Provider Details

I. General information

NPI: 1518022151
Provider Name (Legal Business Name): GREEN VALLEY ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 GARDNER STREET
PATTEN ME
04765
US

IV. Provider business mailing address

69 DAVID STREET PO BOX 127
ISLAND FALLS ME
04747-0127
US

V. Phone/Fax

Practice location:
  • Phone: 207-528-2064
  • Fax: 207-463-2151
Mailing address:
  • Phone: 207-463-2156
  • Fax: 207-463-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberALLS 2244
License Number StateME

VIII. Authorized Official

Name: ERIC C. QUINT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 207-463-2156