Provider Demographics
NPI:1891801601
Name:GREEN CLINIC LLC
Entity Type:Organization
Organization Name:GREEN CLINIC LLC
Other - Org Name:GREEN CLINIC REHABILITATION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:INDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-255-3690
Mailing Address - Street 1:PO BOX 1594
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-1594
Mailing Address - Country:US
Mailing Address - Phone:318-251-6103
Mailing Address - Fax:318-251-6141
Practice Address - Street 1:1200 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5941
Practice Address - Country:US
Practice Address - Phone:318-251-6103
Practice Address - Fax:318-251-6141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREEN CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-22
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CR78Medicare ID - Type Unspecified
LA0599520002Medicare NSC