Healthcare Provider Details

I. General information

NPI: 1255338398
Provider Name (Legal Business Name): GREEN VALLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 ADKINS ST
EUGENE OR
97401-5003
US

IV. Provider business mailing address

1077 GATEWAY LOOP
SPRINGFIELD OR
97477-1114
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-5032
  • Fax: 541-683-5085
Mailing address:
  • Phone: 541-746-1020
  • Fax: 541-284-7072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number800263
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier800263
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MR. MARK GARBER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 541-746-1020