Healthcare Provider Details

I. General information

NPI: 1386701118
Provider Name (Legal Business Name): GREEN RIDGE HEALTH CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 BOULEVARD AVE
SCRANTON PA
18509-1000
US

IV. Provider business mailing address

2741 BOULEVARD AVE
SCRANTON PA
18509-1000
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-6121
  • Fax:
Mailing address:
  • Phone: 570-344-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number332302
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1008394040001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: ELLEN CRAVEN
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 570-344-6121