Provider Demographics
NPI:1053423681
Name:GREEN COUNTRY HOME CARE, INC.
Entity type:Organization
Organization Name:GREEN COUNTRY HOME CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:EZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-687-8033
Mailing Address - Street 1:3310 CHANDLER RD
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-4906
Mailing Address - Country:US
Mailing Address - Phone:918-687-8033
Mailing Address - Fax:918-687-4092
Practice Address - Street 1:405 E CHICKASAW AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5351
Practice Address - Country:US
Practice Address - Phone:918-426-3700
Practice Address - Fax:918-426-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7094251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK377206Medicare Oscar/Certification
37-7206Medicare ID - Type Unspecified