Healthcare Provider Details

I. General information

NPI: 1124187554
Provider Name (Legal Business Name): GREENE PAK PSYCHIATRIC SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 N DETROIT ST
XENIA OH
45385
US

IV. Provider business mailing address

76 FORDWAY DR STE 2
VANDALIA OH
45377
US

V. Phone/Fax

Practice location:
  • Phone: 937-374-6010
  • Fax: 937-374-6014
Mailing address:
  • Phone: 937-890-3139
  • Fax: 937-890-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateOH

VIII. Authorized Official

Name: MAHMOOD RAHMAN
Title or Position: OWNER
Credential: MD
Phone: 937-374-6010