Provider Demographics
NPI:1992089312
Name:GREEN, JUSTIN LEE (DC)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:386 LEISURE LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-8529
Mailing Address - Country:US
Mailing Address - Phone:317-490-2648
Mailing Address - Fax:
Practice Address - Street 1:1185 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-5156
Practice Address - Country:US
Practice Address - Phone:317-884-0995
Practice Address - Fax:317-882-7882
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002603A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400059243Medicare PIN