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General NPI Number Information
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NPI Number | 1114330438
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Entity Type | Organization
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Legal Business Name | GREENFIELDS ICF-DDN
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Dates
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Enumeration Date | 06/04/2014
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Last Update Date | 06/04/2014
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Provider Practice Location Address
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Address Line | 100 MORGAN CT
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City | VALLEJO
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State | CA
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Zip | 94591-8452
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Country | US
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Telephone | 707-553-2935
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Fax | 707-552-1267
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Provider Business Mailing Address
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Address Line | 400 SANTA CLARA ST SUITE 200
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City | VALLEJO
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State | CA
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Zip | 94590-5983
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Country | US
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Telephone | 707-553-2935
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Fax | 707-552-1267
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TERESITA REYES
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Credential | RN
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Telephone | 707-553-2935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 01000433
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License Number State | CA
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