Provider Demographics
NPI:1548420086
Name:MS GREENBOUGH LLC
Entity Type:Organization
Organization Name:MS GREENBOUGH LLC
Other - Org Name:GREENBOUGH HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-430-0000
Mailing Address - Street 1:40 PALAFOX PL
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 DESOTO AVENUE EXT
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-2814
Practice Address - Country:US
Practice Address - Phone:662-627-3486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GULF COAST FACILITIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS255294Medicare Oscar/Certification