Provider Demographics
NPI:1053503888
Name:GREEN RIVER DISTRICT HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:GREEN RIVER DISTRICT HEALTH DEPARTMENT
Other - Org Name:SEBREE ELEMENTARY HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-686-7747
Mailing Address - Street 1:61 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:SEBREE
Mailing Address - State:KY
Mailing Address - Zip Code:42455-2155
Mailing Address - Country:US
Mailing Address - Phone:270-835-7891
Mailing Address - Fax:270-835-7891
Practice Address - Street 1:61 N STATE ST
Practice Address - Street 2:
Practice Address - City:SEBREE
Practice Address - State:KY
Practice Address - Zip Code:42455-2155
Practice Address - Country:US
Practice Address - Phone:270-835-7891
Practice Address - Fax:270-835-7891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20001616Medicaid