Provider Demographics
NPI:1013574532
Name:GREEN HEALTHCARE CLINIC LLC
Entity Type:Organization
Organization Name:GREEN HEALTHCARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-937-0552
Mailing Address - Street 1:825 WOODLEA RD
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-8199
Mailing Address - Country:US
Mailing Address - Phone:815-937-0552
Mailing Address - Fax:
Practice Address - Street 1:4425 W 63RD ST STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5565
Practice Address - Country:US
Practice Address - Phone:888-876-7012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty