Provider Demographics
NPI:1912190208
Name:GREEN ACRES REGIONAL CTR INC
Entity Type:Organization
Organization Name:GREEN ACRES REGIONAL CTR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-762-2520
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:7830 OHIO RIVER ROAD
Mailing Address - City:LESAGE
Mailing Address - State:WV
Mailing Address - Zip Code:25537
Mailing Address - Country:US
Mailing Address - Phone:304-762-2522
Mailing Address - Fax:304-762-2862
Practice Address - Street 1:7830 OHIO RIVER ROAD
Practice Address - Street 2:
Practice Address - City:LESAGE
Practice Address - State:WV
Practice Address - Zip Code:25537
Practice Address - Country:US
Practice Address - Phone:304-762-2522
Practice Address - Fax:304-762-2862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0005317000251C00000X
0005317002261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005317000Medicaid
WV0005317002OtherREHAB