Provider Demographics
NPI:1891069761
Name:THE M.E. GREEN HOUSE
Entity Type:Organization
Organization Name:THE M.E. GREEN HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANI
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-554-8638
Mailing Address - Street 1:139 PINEHURST AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7099
Mailing Address - Country:US
Mailing Address - Phone:910-725-1246
Mailing Address - Fax:803-693-0829
Practice Address - Street 1:139 PINEHURST AVE STE A
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7099
Practice Address - Country:US
Practice Address - Phone:803-554-9683
Practice Address - Fax:803-693-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-063-102251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8303591Medicaid