Provider Demographics
NPI:1124081278
Name:GREEN VALLEY SNF LLC
Entity type:Organization
Organization Name:GREEN VALLEY SNF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:FAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOSHANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-551-4803
Mailing Address - Street 1:400 RELLA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3034 S DUPONT BLVD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1898
Practice Address - Country:US
Practice Address - Phone:302-653-5085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1160314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001088512Medicaid
155A20OtherBLUE CROSS
DE0001088411Medicaid
DE085020AMedicare Oscar/Certification