Provider Demographics
NPI:1215770979
Name:GREENHEAVEN BOARDING HOME LLC
Entity type:Organization
Organization Name:GREENHEAVEN BOARDING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAINA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:214-695-2894
Mailing Address - Street 1:2335 ASPEN HILL DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-3942
Mailing Address - Country:US
Mailing Address - Phone:214-695-2894
Mailing Address - Fax:
Practice Address - Street 1:9119 RUSTOWN DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-4443
Practice Address - Country:US
Practice Address - Phone:214-695-2894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care