Provider Demographics
NPI:1891965356
Name:GREEN VALLEY ENTERPRISES, INC.
Entity Type:Organization
Organization Name:GREEN VALLEY ENTERPRISES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-887-4282
Mailing Address - Street 1:1223 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2629
Mailing Address - Country:US
Mailing Address - Phone:920-887-4282
Mailing Address - Fax:920-887-4292
Practice Address - Street 1:1223 MADISON ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2629
Practice Address - Country:US
Practice Address - Phone:920-887-4282
Practice Address - Fax:920-887-4292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1387-800251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41421000Medicaid