Provider Demographics
NPI:1154777522
Name:GREEN,KARLITA
Entity type:Organization
Organization Name:GREEN,KARLITA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARLITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-920-7506
Mailing Address - Street 1:1928 ABBEYDALE LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-6600
Mailing Address - Country:US
Mailing Address - Phone:910-920-7506
Mailing Address - Fax:910-676-8576
Practice Address - Street 1:1928 ABBEYDALE LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-6600
Practice Address - Country:US
Practice Address - Phone:910-920-7506
Practice Address - Fax:910-676-8576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC88486335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier