Provider Demographics
NPI:1720366602
Name:GREEN, TARA JO (DC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JO
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 1:1736 HWY 80
Mailing Address - Street 2:
Mailing Address - City:CUBA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53807-9708
Mailing Address - Country:US
Mailing Address - Phone:563-209-1749
Mailing Address - Fax:
Practice Address - Street 1:400 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-1902
Practice Address - Country:US
Practice Address - Phone:815-777-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011938111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor