Provider Demographics
NPI:1962221440
Name:GREEN, BROOKE RAE (DC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:RAE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11913 STATE ROUTE 365
Mailing Address - Street 2:
Mailing Address - City:REMSEN
Mailing Address - State:NY
Mailing Address - Zip Code:13438-3366
Mailing Address - Country:US
Mailing Address - Phone:315-525-0166
Mailing Address - Fax:
Practice Address - Street 1:184 MAIN ST REAR
Practice Address - Street 2:
Practice Address - City:EMMAUS
Practice Address - State:PA
Practice Address - Zip Code:18049-4015
Practice Address - Country:US
Practice Address - Phone:610-628-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC012001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor