Basic Information
| Provider Information | |||||||||
| NPI: | 1063405843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENS NURSING AND ASSISTED LIVING, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025967301 | ||||||||
| FaxNumber: | 5025964134 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 BRAINARD RD | ||||||||
| Address2: | |||||||||
| City: | LYNDHURST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441243096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404601000 | ||||||||
| FaxNumber: | 4406460100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5025967300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 5241 | OH | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 5241 | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000156869 | 01 | OH | ANTHEM BLUE CROSS/ BLUE S | OTHER | 27-58332 | 05 | OH | MEDICAID |