Provider Demographics
NPI:1073226700
Name:GREENACRES RESIDENTIAL CARE , LLC
Entity Type:Organization
Organization Name:GREENACRES RESIDENTIAL CARE , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:SEMBEKA
Authorized Official - Last Name:CORSON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:509-200-1455
Mailing Address - Street 1:23033 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7505
Mailing Address - Country:US
Mailing Address - Phone:509-200-1455
Mailing Address - Fax:
Practice Address - Street 1:17927 E APPLEWAY AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99016-9302
Practice Address - Country:US
Practice Address - Phone:509-200-1455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health