MEDICARE: GREEN ACRE LODGE 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	310400000X	Assisted Living Facility	03-009	AR

General Provider Information

NPI Number	:	1942357405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN ACRE LODGE INC.

Provider Business Mailing Address
First Line	:	89 HILLSIDE DR
Second Line	:
City	:	HOLIDAY ISLAND
State	:	AR
Zip	:	72631-4618
Country	:	US
Telephone Number	:	479-253-6553
Fax Number	:	479-253-5043

Provider Business Practice Location Address
First Line	:	89 HILLSIDE DR
Second Line	:
City	:	HOLIDAY ISLAND
State	:	AR
Zip	:	72631-4618
Country	:	US
Telephone Number	:	479-253-6553
Fax Number	:	479-253-5043

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. PERLA TALEBI
Credential	:	R.N.
Telephone Number	:	479-253-6553

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	08/22/2020

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