Healthcare Provider Details

I. General information

NPI: 1245398130
Provider Name (Legal Business Name): GREEN ACRES REGIONAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7830 OHIO RIVER ROAD
LESAGE WV
25537
US

IV. Provider business mailing address

PO BOX 240 7830 OHIO RIVER ROAD
LESAGE WV
25537
US

V. Phone/Fax

Practice location:
  • Phone: 304-762-2522
  • Fax: 304-762-2862
Mailing address:
  • Phone: 304-762-2522
  • Fax: 304-762-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. EMMA SUE SMITH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 304-762-2522