Provider Demographics
NPI:1285689711
Name:GREEN RIVER REGIONAL MENTAL HEALTH/MENTAL RETARDATION BOARD, INC.
Entity Type:Organization
Organization Name:GREEN RIVER REGIONAL MENTAL HEALTH/MENTAL RETARDATION BOARD, INC.
Other - Org Name:RIVERVALLEY BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-689-6540
Mailing Address - Street 1:P.O. BOX 1637
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302
Mailing Address - Country:US
Mailing Address - Phone:270-689-6500
Mailing Address - Fax:270-689-6677
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-2956
Practice Address - Country:US
Practice Address - Phone:270-689-6500
Practice Address - Fax:270-689-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QD1600X
KY800003261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY29202033Medicaid
KY17010307Medicaid
KY27003011Medicaid
KY29102035Medicaid
KY33900093Medicaid
KY29003010Medicaid
KY30603013Medicaid
KY27003011Medicaid