Provider Demographics
NPI:1114330438
Name:GREENFIELDS ICF-DDN
Entity Type:Organization
Organization Name:GREENFIELDS ICF-DDN
Other - Org Name:GREENFIELDS III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:707-553-2935
Mailing Address - Street 1:400 SANTA CLARA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5983
Mailing Address - Country:US
Mailing Address - Phone:707-553-2935
Mailing Address - Fax:707-552-1267
Practice Address - Street 1:100 MORGAN CT
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-8452
Practice Address - Country:US
Practice Address - Phone:707-553-2935
Practice Address - Fax:707-552-1267
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENFIELDS ICF-DDN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01000433320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities