Healthcare Provider Details

I. General information

NPI: 1790980548
Provider Name (Legal Business Name): GREEN MEADOWS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N NEW MADRID ST
SIKESTON MO
63801-1971
US

IV. Provider business mailing address

PO BOX 909
SIKESTON MO
63801-0909
US

V. Phone/Fax

Practice location:
  • Phone: 573-471-5503
  • Fax:
Mailing address:
  • Phone: 573-471-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA DAWN HICKS-MASTER
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential: APN
Phone: 870-243-3960