Healthcare Provider Details

I. General information

NPI: 1255465928
Provider Name (Legal Business Name): N & R OF GREENE HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S WEST AVE
SPRINGFIELD MO
65802-9999
US

IV. Provider business mailing address

910 S WEST AVE
SPRINGFIELD MO
65802-9999
US

V. Phone/Fax

Practice location:
  • Phone: 417-865-8741
  • Fax: 417-865-7601
Mailing address:
  • Phone: 417-865-8741
  • Fax: 417-865-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number034476
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101477107
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier153818
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name: JAMES C LINCOLN
Title or Position: MEMBER
Credential:
Phone: 573-481-9625