Provider Demographics
NPI:1427628759
Name:GREEN RIVER CONGREGATE LIVING
Entity type:Organization
Organization Name:GREEN RIVER CONGREGATE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAPARTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-803-0930
Mailing Address - Street 1:1883 W ROYAL HUNTE DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-4000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2405 INDEPENDENCE CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5743
Practice Address - Country:US
Practice Address - Phone:702-874-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1508260340Medicaid