MEDICARE: GREEN MEADOWS ASSISTED LIVING LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1710678065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN MEADOWS ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	1103 S ONEIDA ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-2453
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1103 S ONEIDA ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-2453
Country	:	US
Telephone Number	:	614-316-4299
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	MR. AHMED SAID
Credential	:
Telephone Number	:	614-316-4299

Provider Enumeration Date	:	05/17/2023
Last Update Date	:	05/17/2023

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