Provider Demographics
NPI:1598589038
Name:GREEN HAVEN IRTS LLC
Entity type:Organization
Organization Name:GREEN HAVEN IRTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:EGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-347-1747
Mailing Address - Street 1:1500 MCANDREWS RD W STE 203
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4445
Mailing Address - Country:US
Mailing Address - Phone:763-485-1011
Mailing Address - Fax:
Practice Address - Street 1:513 WOOD WAY
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5732
Practice Address - Country:US
Practice Address - Phone:763-485-1011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-12
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No283Q00000XHospitalsPsychiatric Hospital