1336142645 NPI number — PROGRESSIVE GREEN MEADOWS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336142645 NPI number — PROGRESSIVE GREEN MEADOWS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE GREEN MEADOWS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GREEN MEADOWS HEALTH AND WELLNESS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336142645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7770 COLUMBUS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44641-9773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-661-6800
Provider Business Mailing Address Fax Number:
216-739-3789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7770 COLUMBUS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44641-9773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-661-6800
Provider Business Practice Location Address Fax Number:
216-739-3789
Provider Enumeration Date:
05/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHILLER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
440-684-9220

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2298N , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2303046 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000299600 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 31-1504075.179 . This is a "MEDICAL MUTUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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