Provider Demographics
NPI:1154583219
Name:GREENFIELDS INTERMEDIATE CARE FACILITY
Entity type:Organization
Organization Name:GREENFIELDS INTERMEDIATE CARE FACILITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RN ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:CABAB
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:707-553-2935
Mailing Address - Street 1:101 HAWKESBURY WAY
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-4337
Mailing Address - Country:US
Mailing Address - Phone:707-553-2935
Mailing Address - Fax:707-553-2993
Practice Address - Street 1:101 HAWKESBURY WAY
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-4337
Practice Address - Country:US
Practice Address - Phone:707-553-2935
Practice Address - Fax:707-553-2993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000659320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities