MEDICARE: GREEN ACRES RESIDENTIAL CARE FACILITY, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	043352	MO

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

General Provider Information

NPI Number	:	1861868135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN ACRES RESIDENTIAL CARE FACILITY, LLC

Provider Business Mailing Address
First Line	:	3688 SAND CREEK RD
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-7350
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3688 SAND CREEK RD
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-7350
Country	:	US
Telephone Number	:	573-756-2917
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HOLLY GREEN
Credential	:
Telephone Number	:	573-756-2917

Provider Enumeration Date	:	08/20/2015
Last Update Date	:	08/20/2015

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