Healthcare Provider Details

I. General information

NPI: 1194015784
Provider Name (Legal Business Name): GREEN RIDGE HEALTHCARE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 BOULEVARD AVE
SCRANTON PA
18509-1000
US

IV. Provider business mailing address

23700 COMMERCE PARK
BEACHWOOD OH
44122-5827
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-6121
  • Fax: 570-344-5171
Mailing address:
  • Phone: 216-292-5706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1026046300001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: WILLIAM I WEISBERG
Title or Position: PRESIDENT
Credential:
Phone: 216-292-5706