Provider Demographics
NPI:1205052081
Name:GREEN, JUSTIN WAYMON (DC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WAYMON
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7855 RALSTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-2462
Mailing Address - Country:US
Mailing Address - Phone:303-425-7205
Mailing Address - Fax:
Practice Address - Street 1:7855 RALSTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80002-2462
Practice Address - Country:US
Practice Address - Phone:303-425-7205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU46303Medicare UPIN