Provider Demographics
NPI:1265680383
Name:GREEN, BRET
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:
Last Name:GREEN
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 1:180 SOUTH MARION STREET
Mailing Address - Street 2:
Mailing Address - City:WALDO
Mailing Address - State:OH
Mailing Address - Zip Code:43356
Mailing Address - Country:US
Mailing Address - Phone:937-578-4061
Mailing Address - Fax:
Practice Address - Street 1:180 SOUTH MARION STREET
Practice Address - Street 2:
Practice Address - City:WALDO
Practice Address - State:OH
Practice Address - Zip Code:43356
Practice Address - Country:US
Practice Address - Phone:937-578-4061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker