Provider Demographics
NPI:1699772327
Name:THE GREEN HOME
Entity type:Organization
Organization Name:THE GREEN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:C
Authorized Official - Last Name:YOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-321-3175
Mailing Address - Street 1:37 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1857
Mailing Address - Country:US
Mailing Address - Phone:570-724-3131
Mailing Address - Fax:570-724-2367
Practice Address - Street 1:37 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1857
Practice Address - Country:US
Practice Address - Phone:570-724-3131
Practice Address - Fax:570-724-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA072202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007565790003Medicaid
PA395318Medicare ID - Type UnspecifiedPROVIDER NUMBER
PA0007565790003Medicaid