Basic Information
| Provider Information | |||||||||
| NPI: | 1073509345 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | N & R OF GREENVILLE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GREENVILLE HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 108 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639440108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732243298 | ||||||||
| FaxNumber: | 5732245338 | ||||||||
| Practice Location | |||||||||
| Address1: | SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732243298 | ||||||||
| FaxNumber: | 5732245338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 04/25/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUDSPETH | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO CFO | ||||||||
| AuthorizedOfficialTelephone: | 5733920316 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 029954 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 16877942 | 01 | MO | STATE ID | OTHER | 102758307 | 05 | MO | MEDICAID |