Provider Demographics
NPI:1760925960
Name:GREENE, BRANDON ALLEN (MAT)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:ALLEN
Last Name:GREENE
Suffix:
Gender:M
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 S KING ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2254
Mailing Address - Country:US
Mailing Address - Phone:808-518-0071
Mailing Address - Fax:
Practice Address - Street 1:1281 S KING ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2254
Practice Address - Country:US
Practice Address - Phone:808-593-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14881174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist