Provider Demographics
NPI:1396152963
Name:GREEN ACRES
Entity type:Organization
Organization Name:GREEN ACRES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:T
Authorized Official - Last Name:KALBARCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-861-2975
Mailing Address - Street 1:15820 ARCHER ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-3816
Mailing Address - Country:US
Mailing Address - Phone:727-861-2975
Mailing Address - Fax:727-857-4533
Practice Address - Street 1:15820 ARCHER ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-3816
Practice Address - Country:US
Practice Address - Phone:727-861-2975
Practice Address - Fax:727-857-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAI8642310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140906900Medicaid