Basic Information
| Provider Information | |||||||||
| NPI: | 1154557015 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREEN VALLEY HOME CARE, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDICAL SERVICES OF AMERICA HOME HEALTH & HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1928 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290711928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039570500 | ||||||||
| FaxNumber: | 8883426190 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 RENAISSANCE DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891196199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025681176 | ||||||||
| FaxNumber: | 7025681194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2009 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JEFFCOAT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8039570500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 1154557015 | 05 | NV | MEDICAID |