Healthcare Provider Details

I. General information

NPI: 1386621613
Provider Name (Legal Business Name): GREEN PARK NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 GREEN PARK RD
SAINT LOUIS MO
63123-7211
US

IV. Provider business mailing address

9350 GREEN PARK RD
SAINT LOUIS MO
63123-7211
US

V. Phone/Fax

Practice location:
  • Phone: 314-845-0900
  • Fax: 314-845-0901
Mailing address:
  • Phone: 314-845-0900
  • Fax: 314-845-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031930
License Number StateMO

VIII. Authorized Official

Name: MISS DONNA MARIE HARP
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 314-845-0900