Provider Demographics
NPI:1336219146
Name:GREENLEAF SENIOR CARE INC
Entity Type:Organization
Organization Name:GREENLEAF SENIOR CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-955-4145
Mailing Address - Street 1:1305 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2117
Mailing Address - Country:US
Mailing Address - Phone:515-955-4145
Mailing Address - Fax:515-955-1731
Practice Address - Street 1:1305 N 22ND ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-2117
Practice Address - Country:US
Practice Address - Phone:515-955-4145
Practice Address - Fax:515-955-1731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA940016251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0896365Medicaid
IA0809335Medicaid
IA0896365Medicaid