Provider Demographics
NPI:1881663029
Name:GREEN, ALBERT HARRIS (ATC, EMT)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:HARRIS
Last Name:GREEN
Suffix:
Gender:M
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 CREWS LAKE HILLS LOOP N
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3861
Mailing Address - Country:US
Mailing Address - Phone:863-670-4311
Mailing Address - Fax:863-644-8650
Practice Address - Street 1:2504 CREWS LAKE HILLS LOOP N
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3861
Practice Address - Country:US
Practice Address - Phone:863-670-4311
Practice Address - Fax:863-644-8650
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer