Provider Demographics
NPI:1083072250
Name:GREEN MEADOWS WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:GREEN MEADOWS WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR.
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-280-5581
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:KY
Mailing Address - Zip Code:40771-0098
Mailing Address - Country:US
Mailing Address - Phone:606-280-5581
Mailing Address - Fax:
Practice Address - Street 1:1640 MEADOW CREEK ROAD
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:KY
Practice Address - Zip Code:40771
Practice Address - Country:US
Practice Address - Phone:606-280-5581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty