MEDICARE: GREEN RAVEN INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	25613	TX
3	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2099571	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134222482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN RAVEN INC

Provider Business Mailing Address
First Line	:	1623 E HIGHWAY 83
Second Line	:
City	:	RIO GRANDE CITY
State	:	TX
Zip	:	78582
Country	:	US
Telephone Number	:	956-488-1660
Fax Number	:	956-488-1491

Provider Business Practice Location Address
First Line	:	1623 E HIGHWAY 83
Second Line	:
City	:	RIO GRANDE CITY
State	:	TX
Zip	:	78582
Country	:	US
Telephone Number	:	956-488-1660
Fax Number	:	956-488-1491

Authorized Official
Title or Position	:	OWNER
Name	:	JUAN GARCIA
Credential	:
Telephone Number	:	956-849-3476

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	04/29/2025

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Directions to “GREEN RAVEN INC ” Practice Location

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