Provider Demographics
NPI:1144868746
Name:GREEN RIVER HOSPICE
Entity type:Organization
Organization Name:GREEN RIVER HOSPICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-643-6250
Mailing Address - Street 1:17332 IRVINE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3059
Mailing Address - Country:US
Mailing Address - Phone:949-550-1850
Mailing Address - Fax:949-550-1878
Practice Address - Street 1:17332 IRVINE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3059
Practice Address - Country:US
Practice Address - Phone:949-550-1850
Practice Address - Fax:949-550-1878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based