Provider Demographics
NPI:1972840452
Name:GREEN, MELVIN RICHARD JR (LMT)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:RICHARD
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 LOST CREEK ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-1325
Mailing Address - Country:US
Mailing Address - Phone:210-313-6994
Mailing Address - Fax:
Practice Address - Street 1:2106 E SONTERRA BLVD STE 111
Practice Address - Street 2:STUDIO 42
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-7608
Practice Address - Country:US
Practice Address - Phone:210-313-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLMT 100005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist