Provider Demographics
NPI:1437295359
Name:GREEN VALLEY ASSOCIATION
Entity Type:Organization
Organization Name:GREEN VALLEY ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:QUINT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-463-2156
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:ISLAND FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04747-0127
Mailing Address - Country:US
Mailing Address - Phone:207-463-2156
Mailing Address - Fax:207-463-2151
Practice Address - Street 1:13 GARDNER STREET
Practice Address - Street 2:
Practice Address - City:PATTEN
Practice Address - State:ME
Practice Address - Zip Code:04765
Practice Address - Country:US
Practice Address - Phone:207-528-2064
Practice Address - Fax:207-463-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 2244320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104300300Medicaid