Provider Demographics
NPI:1477614519
Name:DR REBECCA GREEN
Entity Type:Organization
Organization Name:DR REBECCA GREEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC DACBSP
Authorized Official - Phone:860-537-8900
Mailing Address - Street 1:121 BROADWAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415
Mailing Address - Country:US
Mailing Address - Phone:860-537-8900
Mailing Address - Fax:860-537-8868
Practice Address - Street 1:121 BROADWAY
Practice Address - Street 2:SUITE 2
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415
Practice Address - Country:US
Practice Address - Phone:860-537-8900
Practice Address - Fax:860-537-8868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001023111N00000X
RI0CP00506111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001023CT04OtherBLUE CROSS BLUE SHIELD
CTCT01023OtherHEALTHNET
CT3984974OtherAETNA
CT3984974OtherAETNA