Provider Demographics
NPI:1962602821
Name:GREEN VALLEY RURAL CLINICS, LLC
Entity type:Organization
Organization Name:GREEN VALLEY RURAL CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DJIEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-432-3221
Mailing Address - Street 1:PO BOX 2748
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2748
Mailing Address - Country:US
Mailing Address - Phone:606-432-3221
Mailing Address - Fax:606-437-0438
Practice Address - Street 1:156 ISLAND CREEK RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9340
Practice Address - Country:US
Practice Address - Phone:606-432-3221
Practice Address - Fax:606-437-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65925638Medicaid
KY65925638Medicaid