Provider Demographics
NPI:1497919005
Name:GREENE, MARK A (LMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GREENE
Suffix:
Gender:M
Credentials:LMT
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 770666
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34477-0666
Mailing Address - Country:US
Mailing Address - Phone:352-237-5455
Mailing Address - Fax:352-237-5455
Practice Address - Street 1:6440 SW 73RD ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34476-5568
Practice Address - Country:US
Practice Address - Phone:352-237-5455
Practice Address - Fax:352-237-5455
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-12
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31236225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist