Provider Demographics
NPI:1871932772
Name:GREEN ACRE LLC
Entity type:Organization
Organization Name:GREEN ACRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:601-503-4432
Mailing Address - Street 1:221 JACKS PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-4450
Mailing Address - Country:US
Mailing Address - Phone:602-503-4432
Mailing Address - Fax:
Practice Address - Street 1:1214 SHARON RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-8814
Practice Address - Country:US
Practice Address - Phone:601-503-4432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care