Provider Demographics
NPI:1003033085
Name:GREEN RIVER AREA DEVELOPMENT DISTRICT
Entity Type:Organization
Organization Name:GREEN RIVER AREA DEVELOPMENT DISTRICT
Other - Org Name:GREEN RIVER AREA AGENCY ON AGING
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JITEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-926-4433
Mailing Address - Street 1:300 GRADD WAY
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-8696
Mailing Address - Country:US
Mailing Address - Phone:270-926-4433
Mailing Address - Fax:270-684-0714
Practice Address - Street 1:300 GRADD WAY
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-8696
Practice Address - Country:US
Practice Address - Phone:270-926-4433
Practice Address - Fax:270-684-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251B00000X, 251C00000X, 251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY17000720Medicaid
KY33001371Medicaid
KY43996032Medicaid