Provider Demographics
NPI:1922523505
Name:GREEN ACRES AFC
Entity Type:Organization
Organization Name:GREEN ACRES AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:AFC LICENSEE
Authorized Official - Phone:231-632-8810
Mailing Address - Street 1:9822 N LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-9106
Mailing Address - Country:US
Mailing Address - Phone:231-632-8810
Mailing Address - Fax:
Practice Address - Street 1:127 POTTER RD W
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-8525
Practice Address - Country:US
Practice Address - Phone:231-947-7055
Practice Address - Fax:231-947-7060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG280278926253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAG280278926Medicaid
MIAG280278926OtherADULT FOSTER CARE