Provider Demographics
NPI:1194994350
Name:RICHARD S. GREEN
Entity type:Organization
Organization Name:RICHARD S. GREEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-631-1530
Mailing Address - Street 1:13210 SE 240TH ST STE C2
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-5182
Mailing Address - Country:US
Mailing Address - Phone:253-631-1530
Mailing Address - Fax:253-631-5262
Practice Address - Street 1:13210 SE 240TH ST STE C2
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-5182
Practice Address - Country:US
Practice Address - Phone:253-631-1530
Practice Address - Fax:253-631-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001857Medicaid
WA5570720001Medicare NSC
WAT01614Medicare UPIN