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General NPI Number Information
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NPI Number | 1184425092
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Entity Type | Organization
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Legal Business Name | GREEN TREE RESIDENCE LLC
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Dates
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Enumeration Date | 03/24/2025
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Last Update Date | 03/24/2025
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Provider Practice Location Address
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Address Line | 13741 BURNING TREE DR
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City | VICTORVILLE
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State | CA
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Zip | 92395-4806
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Country | US
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Telephone | 760-245-2504
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Fax |
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Provider Business Mailing Address
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Address Line | 13741 BURNING TREE DR
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City | VICTORVILLE
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State | CA
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Zip | 92395-4806
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Country | US
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Telephone | 760-245-2504
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. MARTIN MICHAEL VENTRESS JR.
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Credential |
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Telephone | 424-634-0093
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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