MEDICARE: MRS. STEPHANIE A GREEN GROUP HOME PROVIDER

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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1417608357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE A GREEN GROUP HOME PROVIDER

Provider Business Mailing Address
First Line	:	4941 GARY DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-3633
Country	:	US
Telephone Number	:	239-410-7524
Fax Number	:	239-694-1994

Provider Business Practice Location Address
First Line	:	4941 GARY DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-3633
Country	:	US
Telephone Number	:	239-410-7524
Fax Number	:	239-694-1994

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	01/12/2022

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