Provider Demographics
NPI:1891055687
Name:GREEN, GARY BLAINE
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:BLAINE
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 1:5303 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-5823
Mailing Address - Country:US
Mailing Address - Phone:806-799-8950
Mailing Address - Fax:806-792-9404
Practice Address - Street 1:5303 50TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-5823
Practice Address - Country:US
Practice Address - Phone:806-799-8950
Practice Address - Fax:806-792-9404
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT0797237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist