Provider Demographics
NPI:1003216177
Name:GREEN, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
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 1:300 HUNTINGDON DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-8830
Mailing Address - Country:US
Mailing Address - Phone:619-694-7780
Mailing Address - Fax:
Practice Address - Street 1:300 HUNTINGDON DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-8830
Practice Address - Country:US
Practice Address - Phone:619-694-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJG730509661028922255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer