Provider Demographics
NPI:1093312142
Name:GREEN, JUSTIN TAYLOR
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TAYLOR
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 1:1052 AIRSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5559
Mailing Address - Country:US
Mailing Address - Phone:562-347-8719
Mailing Address - Fax:
Practice Address - Street 1:1760 TERMINO AVE STE 208
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2151
Practice Address - Country:US
Practice Address - Phone:562-961-5655
Practice Address - Fax:562-961-8819
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246ZC0007X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant