Provider Demographics
NPI:1275283921
Name:GREEN, JOHNNY RAY JR
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:RAY
Last Name:GREEN
Suffix:JR
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 1:20214 E ADMIRAL PL APT 732
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-3265
Mailing Address - Country:US
Mailing Address - Phone:870-680-0227
Mailing Address - Fax:
Practice Address - Street 1:20214 E ADMIRAL PL APT 732
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-3265
Practice Address - Country:US
Practice Address - Phone:870-680-0227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator