=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154029759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING GREENS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2023
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24796 GREENTREE LN
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-636-4968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1112
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92609-1112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARYANNA MCGERVEY
-----------------------------------------------------
Credential | RDN, MPH, MBA
-----------------------------------------------------
Telephone | 818-636-4968
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------