Provider Demographics
NPI:1699838029
Name:GREEN PINE ACRES
Entity Type:Organization
Organization Name:GREEN PINE ACRES
Other - Org Name:MENAHGA HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAIR
Authorized Official - Middle Name:E
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-564-4101
Mailing Address - Street 1:427 MAIN ST NE
Mailing Address - Street 2:
Mailing Address - City:MENAHGA
Mailing Address - State:MN
Mailing Address - Zip Code:56464-8702
Mailing Address - Country:US
Mailing Address - Phone:218-564-4101
Mailing Address - Fax:218-564-5309
Practice Address - Street 1:427 MAIN ST NE
Practice Address - Street 2:
Practice Address - City:MENAHGA
Practice Address - State:MN
Practice Address - Zip Code:56464-8702
Practice Address - Country:US
Practice Address - Phone:218-564-4101
Practice Address - Fax:218-564-5309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331360251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN812524400Medicaid
FM4980316OtherMEDICA