Provider Demographics
NPI:1104901578
Name:GREEN OPTICAL
Entity type:Organization
Organization Name:GREEN OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-452-1602
Mailing Address - Street 1:854 LONE OAK DR
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-3694
Mailing Address - Country:US
Mailing Address - Phone:615-452-1602
Mailing Address - Fax:615-452-9643
Practice Address - Street 1:854 LONE OAK DR
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066
Practice Address - Country:US
Practice Address - Phone:615-452-1602
Practice Address - Fax:615-452-9643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP1903OtherEYEMED
021446OtherBLOCK VISION
905714OtherBLOCK VISION
0191345OtherTENNCARE SELECT
632OtherSTERLING VISION
TN3157442OtherBLUE CROSS BLUE SHIELD
905714OtherBLOCK VISION