Provider Demographics
NPI:1124825120
Name:GREEN, TOMMY
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 GLADES ROAD
Mailing Address - Street 2:SUITE 500 #1158
Mailing Address - City:BOCA RATON, FL
Mailing Address - State:FL
Mailing Address - Zip Code:33431
Mailing Address - Country:US
Mailing Address - Phone:561-316-6920
Mailing Address - Fax:
Practice Address - Street 1:5550 GLADES ROAD
Practice Address - Street 2:SUITE 500 #1158
Practice Address - City:BOCA RATON, FL
Practice Address - State:FL
Practice Address - Zip Code:33431-3343
Practice Address - Country:US
Practice Address - Phone:561-316-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver