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General NPI Number Information
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NPI Number | 1598589038
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Entity Type | Organization
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Legal Business Name | GREEN HAVEN IRTS LLC
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Dates
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Enumeration Date | 11/12/2024
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 513 WOOD WAY
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City | BURNSVILLE
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State | MN
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Zip | 55337-5732
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Country | US
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Telephone | 763-485-1011
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 MCANDREWS RD W STE 203
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City | BURNSVILLE
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State | MN
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Zip | 55337-4445
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Country | US
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Telephone | 763-485-1011
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MOHAMOUD EGAL
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Credential |
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Telephone | 651-347-1747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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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 | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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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 | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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