Provider Demographics
NPI:1184425092
Name:GREEN TREE RESIDENCE LLC
Entity type:Organization
Organization Name:GREEN TREE RESIDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:VENTRESS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:424-634-0093
Mailing Address - Street 1:13741 BURNING TREE DR
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4806
Mailing Address - Country:US
Mailing Address - Phone:760-245-2504
Mailing Address - Fax:
Practice Address - Street 1:13741 BURNING TREE DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4806
Practice Address - Country:US
Practice Address - Phone:760-245-2504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility