Provider Demographics
NPI:1831550847
Name:GREEN STREET ALF, CORP
Entity type:Organization
Organization Name:GREEN STREET ALF, CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:E
Authorized Official - Last Name:CABALLERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-274-0144
Mailing Address - Street 1:12262 SW 250TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5952
Mailing Address - Country:US
Mailing Address - Phone:786-274-0144
Mailing Address - Fax:855-299-0714
Practice Address - Street 1:12262 SW 250TH TER
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5952
Practice Address - Country:US
Practice Address - Phone:786-274-0144
Practice Address - Fax:855-299-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12805310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility