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General NPI Number Information
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NPI Number | 1366053480
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Entity Type | Organization
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Legal Business Name | GREEN ACRES ASSISTED LIVING LLC
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Dates
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Enumeration Date | 08/12/2020
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Last Update Date | 10/08/2020
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Provider Practice Location Address
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Address Line | 411 N KINGS HIGHWAY
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City | SIKESTON
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State | MO
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Zip | 63801-1936
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Country | US
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Telephone | 573-471-0466
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Fax | 573-471-4918
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Provider Business Mailing Address
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Address Line | 1515 E MALONE AVE
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City | SIKESTON
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State | MO
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Zip | 63801-3413
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Country | US
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Telephone | 573-471-0466
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Fax | 573-471-4918
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Authorized Official
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Title or Position | OWNER
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Name | TERRY COLE
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Credential |
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Telephone | 573-471-0466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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