Provider Demographics
NPI:1164593224
Name:JEAN GREEN
Entity Type:Organization
Organization Name:JEAN GREEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-393-1920
Mailing Address - Street 1:50 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1209
Mailing Address - Country:US
Mailing Address - Phone:508-393-1920
Mailing Address - Fax:
Practice Address - Street 1:588 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-2920
Practice Address - Country:US
Practice Address - Phone:509-393-1920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA843133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALD0054OtherBLUECROSS BLUESHIELD ID
MA39221OtherHARVARD PILGRIM ID
MA725391OtherTUFTS PROVIDER ID
MA39221OtherHARVARD PILGRIM ID
MAGRMT0083Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID