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General NPI Number Information
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NPI Number | 1861868135
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Entity Type | Organization
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Legal Business Name | GREEN ACRES RESIDENTIAL CARE FACILITY, LLC
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Dates
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Enumeration Date | 08/20/2015
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Last Update Date | 08/20/2015
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Provider Practice Location Address
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Address Line | 3688 SAND CREEK RD
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City | FARMINGTON
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State | MO
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Zip | 63640-7350
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Country | US
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Telephone | 573-756-2917
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Fax |
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Provider Business Mailing Address
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Address Line | 3688 SAND CREEK RD
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City | FARMINGTON
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State | MO
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Zip | 63640-7350
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | HOLLY GREEN
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Credential |
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Telephone | 573-756-2917
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 043352
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License Number State | MO
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