Provider Demographics
NPI:1376093203
Name:GREEN THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:GREEN THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMBT
Authorized Official - Phone:919-813-0978
Mailing Address - Street 1:7406 CHAPEL HILL RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607
Mailing Address - Country:US
Mailing Address - Phone:919-813-0978
Mailing Address - Fax:919-800-3344
Practice Address - Street 1:7406 CHAPEL HILL RD
Practice Address - Street 2:SUITE K
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-5077
Practice Address - Country:US
Practice Address - Phone:919-813-0978
Practice Address - Fax:919-800-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14122175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty