Provider Demographics
NPI:1114900347
Name:GREEN, BOBBY G (DC)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:G
Last Name:GREEN
Suffix:
Gender:M
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:CANNELTON HOLLOW RD.
Mailing Address - Street 2:P.O. BOX 200
Mailing Address - City:SMITHERS
Mailing Address - State:WV
Mailing Address - Zip Code:25186
Mailing Address - Country:US
Mailing Address - Phone:304-442-5188
Mailing Address - Fax:304-442-5188
Practice Address - Street 1:RT. 60 & CANNELTON HOLLOW RD.
Practice Address - Street 2:
Practice Address - City:SMITHERS
Practice Address - State:WV
Practice Address - Zip Code:25186
Practice Address - Country:US
Practice Address - Phone:304-442-5188
Practice Address - Fax:304-442-5188
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV705111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7139239OtherAETNA
WVP00254800OtherRAILROAD MEDICARE
WV225670OtherCARELINK
WV7139239OtherAETNA
WVU66371Medicare UPIN