Provider Demographics
NPI:1790980548
Name:GREEN MEADOWS
Entity Type:Organization
Organization Name:GREEN MEADOWS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:HICKS-MASTER
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:870-243-3960
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-0909
Mailing Address - Country:US
Mailing Address - Phone:573-471-5503
Mailing Address - Fax:
Practice Address - Street 1:301 N NEW MADRID ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-1971
Practice Address - Country:US
Practice Address - Phone:573-471-5503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266736404Medicaid