Provider Demographics
NPI:1669202339
Name:GREEN, BRIAN GREEN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:GREEN
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 1:180 SUN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-9075
Mailing Address - Country:US
Mailing Address - Phone:832-909-6859
Mailing Address - Fax:
Practice Address - Street 1:2620 TENDERFOOT HILL ST STE 10
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8354
Practice Address - Country:US
Practice Address - Phone:719-527-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0025030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty