Provider Demographics
NPI:1104914373
Name:REGGIE GREEN
Entity type:Organization
Organization Name:REGGIE GREEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REGGIE
Authorized Official - Middle Name:DEMONE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-644-6514
Mailing Address - Street 1:105 WEST CORNERVIEW
Mailing Address - Street 2:BLDG B
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8509
Mailing Address - Country:US
Mailing Address - Phone:225-803-3122
Mailing Address - Fax:
Practice Address - Street 1:105 W CORNERVIEW ST
Practice Address - Street 2:SUITE B
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2839
Practice Address - Country:US
Practice Address - Phone:225-644-6514
Practice Address - Fax:225-644-6514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02879332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1527297Medicaid
LA5703350001Medicare NSC