Provider Demographics
NPI:1770258568
Name:GREEN HAVEN ADULT DAY PROGRAM LLC
Entity Type:Organization
Organization Name:GREEN HAVEN ADULT DAY PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-393-1639
Mailing Address - Street 1:914 TIMBERWOOD CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-7518
Mailing Address - Country:US
Mailing Address - Phone:314-393-1639
Mailing Address - Fax:
Practice Address - Street 1:6207 N LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2817
Practice Address - Country:US
Practice Address - Phone:314-393-1639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home