Provider Demographics
NPI:1346213071
Name:GREEN, DAVID TYLER (MA, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:TYLER
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 GENERAL NELSON DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8698
Mailing Address - Country:US
Mailing Address - Phone:859-622-2140
Mailing Address - Fax:859-622-8857
Practice Address - Street 1:521 LANCASTER AVE. MOBERLY 203
Practice Address - Street 2:EASTERN KENTUCKY UNIVERSITY
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-622-2140
Practice Address - Fax:859-622-8857
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT024174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist