Provider Demographics
NPI:1134638802
Name:GREENE, SHAVON
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-5331
Mailing Address - Country:US
Mailing Address - Phone:714-443-8638
Mailing Address - Fax:
Practice Address - Street 1:801 S RANCHO DR STE E2B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3812
Practice Address - Country:US
Practice Address - Phone:702-771-5578
Practice Address - Fax:702-771-5578
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner