Provider Demographics
NPI:1124423470
Name:GREEN LIFE ASSISTED LIVING FACILITY, LLC
Entity type:Organization
Organization Name:GREEN LIFE ASSISTED LIVING FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-931-1433
Mailing Address - Street 1:840 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-8214
Mailing Address - Country:US
Mailing Address - Phone:855-331-6615
Mailing Address - Fax:855-638-4902
Practice Address - Street 1:840 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-8214
Practice Address - Country:US
Practice Address - Phone:855-331-6615
Practice Address - Fax:855-638-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12577310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013937500Medicaid
FL009633000Medicaid