Provider Demographics
NPI:1912121716
Name:GREEN MEADOW HAVEN
Entity type:Organization
Organization Name:GREEN MEADOW HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRISOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-932-5006
Mailing Address - Street 1:PO BOX 13524
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-3524
Mailing Address - Country:US
Mailing Address - Phone:318-445-4477
Mailing Address - Fax:
Practice Address - Street 1:1110 RINGGOLD AVE
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9073
Practice Address - Country:US
Practice Address - Phone:318-932-5006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1670553Medicaid
LA1670553Medicaid
LA=========0OtherBLUE CROSS BLUE SHIELD