Provider Demographics
NPI:1528221157
Name:GREEN AND GUIRNALDA FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:GREEN AND GUIRNALDA FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINIQUE
Authorized Official - Middle Name:LEONETTA
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-572-7252
Mailing Address - Street 1:3359 KEMP RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2565
Mailing Address - Country:US
Mailing Address - Phone:937-572-7252
Mailing Address - Fax:937-458-4539
Practice Address - Street 1:3359 KEMP RD STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2565
Practice Address - Country:US
Practice Address - Phone:937-572-7252
Practice Address - Fax:937-458-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2257187Medicaid
OHGR9316911Medicare PIN