Provider Demographics
NPI:1639627243
Name:GREEN, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
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 154
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-0154
Mailing Address - Country:US
Mailing Address - Phone:435-835-4316
Mailing Address - Fax:435-835-4317
Practice Address - Street 1:501 W 2600 S STE 200
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7785
Practice Address - Country:US
Practice Address - Phone:435-835-4316
Practice Address - Fax:435-835-4317
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker