Provider Demographics
NPI:1346545662
Name:BLYDEN-GREEN, LAVORNE
Entity Type:Individual
Prefix:MRS
First Name:LAVORNE
Middle Name:
Last Name:BLYDEN-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:PO BOX 2312
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30237-2312
Mailing Address - Country:US
Mailing Address - Phone:404-781-8166
Mailing Address - Fax:
Practice Address - Street 1:7733 TOWN CT
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2395
Practice Address - Country:US
Practice Address - Phone:404-781-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332900000XSuppliersNon-Pharmacy Dispensing Site
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332U00000XSuppliersHome Delivered Meals
No335E00000XSuppliersProsthetic/Orthotic Supplier
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier