Provider Demographics
NPI:1841914785
Name:GREENHOUSE WELLNESS LLC
Entity type:Organization
Organization Name:GREENHOUSE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KOKNOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:LISMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-794-5070
Mailing Address - Street 1:100 N HEARTHSTONE WAY APT 3168
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-0043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1345 E CHANDLER BLVD BLDG 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-6279
Practice Address - Country:US
Practice Address - Phone:317-794-5070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health