Provider Demographics
NPI:1386621613
Name:GREEN PARK NURSING HOME
Entity type:Organization
Organization Name:GREEN PARK NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HARP
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:314-845-0900
Mailing Address - Street 1:9350 GREEN PARK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7211
Mailing Address - Country:US
Mailing Address - Phone:314-845-0900
Mailing Address - Fax:314-845-0901
Practice Address - Street 1:9350 GREEN PARK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7211
Practice Address - Country:US
Practice Address - Phone:314-845-0900
Practice Address - Fax:314-845-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031930314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO265703Medicare ID - Type Unspecified