Healthcare Provider Details

I. General information

NPI: 1336219146
Provider Name (Legal Business Name): GREENLEAF SENIOR CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 N 22ND ST
FORT DODGE IA
50501-2117
US

IV. Provider business mailing address

1305 N 22ND ST
FORT DODGE IA
50501-2117
US

V. Phone/Fax

Practice location:
  • Phone: 515-955-4145
  • Fax: 515-955-1731
Mailing address:
  • Phone: 515-955-4145
  • Fax: 515-955-1731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number940016
License Number StateIA

VIII. Authorized Official

Name: MS. JUDY FOWLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 515-955-4145