Provider Demographics
NPI:1700575180
Name:GREEN, TECKELA SAMYELL
Entity Type:Individual
Prefix:
First Name:TECKELA
Middle Name:SAMYELL
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8760 LANDMARK RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-2802
Mailing Address - Country:US
Mailing Address - Phone:804-688-0000
Mailing Address - Fax:804-774-7533
Practice Address - Street 1:8760 LANDMARK RD STE A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2802
Practice Address - Country:US
Practice Address - Phone:804-688-0000
Practice Address - Fax:804-774-7533
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier