MEDICARE: GREENLEAF SENIOR CARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency	940016	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336219146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREENLEAF SENIOR CARE INC

Provider Business Mailing Address
First Line	:	1305 N 22ND ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-2117
Country	:	US
Telephone Number	:	515-955-4145
Fax Number	:	515-955-1731

Provider Business Practice Location Address
First Line	:	1305 N 22ND ST
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-2117
Country	:	US
Telephone Number	:	515-955-4145
Fax Number	:	515-955-1731

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. JUDY FOWLER
Credential	:
Telephone Number	:	515-955-4145

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	10/30/2007

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