Provider Demographics
NPI:1265658322
Name:GREEN COUNTRY MEDICAL, INC.
Entity Type:Organization
Organization Name:GREEN COUNTRY MEDICAL, INC.
Other - Org Name:GREEN COUNTRY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:NEELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-273-0140
Mailing Address - Street 1:228 WILLOW
Mailing Address - Street 2:
Mailing Address - City:SOUTH COFFEYVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:228 WILLOW
Practice Address - Street 2:
Practice Address - City:SOUTH COFFEYVILLE
Practice Address - State:OK
Practice Address - Zip Code:74072
Practice Address - Country:US
Practice Address - Phone:918-255-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory