1639383946 NPI number — GREENLEAF ASSISTED LIVING, INC.

Table of content: JESSICA ERIN ROETS OT (NPI 1003054115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639383946 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:
1639383946
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:
326 MAIN AVE, SUITE 208
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:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2015 8TH ST S
Provider Second Line Business Practice Location Address:
GREENLEAF ASSISTED LIVING CENTER
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57006-3506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-692-6311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2007

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:  11055 , 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)





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