1750591194 NPI number — GREENLEAF ASSISTED LIVING, INC.

Table of content: (NPI 1750591194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750591194 NPI number — GREENLEAF ASSISTED LIVING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREENLEAF ASSISTED LIVING, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750591194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8594
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKINGS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57006-8594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-692-1230
Provider Business Mailing Address Fax Number:
605-692-1241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3409 E 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57103-1235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-275-0074
Provider Business Practice Location Address Fax Number:
605-275-0076
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMALES
Authorized Official First Name:
CONSTANTINE
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
OWNER AND OPERATIONS OFFICER
Authorized Official Telephone Number:
605-692-1230

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  47882 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com