Provider Demographics
NPI:1851638084
Name:GREENLIFE IOP PROGRAM
Entity Type:Organization
Organization Name:GREENLIFE IOP PROGRAM
Other - Org Name:RANDALL M GREEN
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAFFUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-746-8232
Mailing Address - Street 1:282 NW 162ND AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1147
Mailing Address - Country:US
Mailing Address - Phone:954-746-8232
Mailing Address - Fax:954-746-8981
Practice Address - Street 1:282 NW 162ND AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1147
Practice Address - Country:US
Practice Address - Phone:954-746-8232
Practice Address - Fax:954-746-8981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1706AD598901324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1706AD598901OtherDCF STATE LICENSE