Provider Demographics
NPI:1558349654
Name:GREEN, LISA ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 NW 1ST CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-8174
Mailing Address - Country:US
Mailing Address - Phone:954-270-5610
Mailing Address - Fax:954-775-3931
Practice Address - Street 1:1304 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-6623
Practice Address - Country:US
Practice Address - Phone:954-977-0888
Practice Address - Fax:954-804-0933
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380828900Medicaid
FLU54799Medicare UPIN
FL55255ZMedicare PIN