Provider Demographics
NPI:1003319161
Name:GREEN, KEVIN BERNARD
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:BERNARD
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 1:10217 WOODLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6663
Mailing Address - Country:US
Mailing Address - Phone:901-736-7089
Mailing Address - Fax:
Practice Address - Street 1:10217 WOODLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6663
Practice Address - Country:US
Practice Address - Phone:901-736-7089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN065153548343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)