Provider Demographics
NPI:1285907485
Name:GREEN, MAYNARD A
Entity type:Individual
Prefix:
First Name:MAYNARD
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 LADERA DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-2048
Mailing Address - Country:US
Mailing Address - Phone:775-445-9392
Mailing Address - Fax:
Practice Address - Street 1:955 LADERA DR
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-2048
Practice Address - Country:US
Practice Address - Phone:775-445-9392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner