=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356057566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN RIVER HORIZONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2023
-----------------------------------------------------
Last Update Date | 01/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 QUISENBERRY RD
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-8005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-937-4898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 451 QUISENBERRY RD
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-8005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-937-4898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING/BILLING
-----------------------------------------------------
Name | CHELSEA COOPER
-----------------------------------------------------
Credential | CREDENTIALING
-----------------------------------------------------
Telephone | 859-270-8099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------