Provider Demographics
NPI:1720152739
Name:GREGORY CHAD GREEN OD
Entity Type:Organization
Organization Name:GREGORY CHAD GREEN OD
Other - Org Name:GREEN FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:G CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:334-289-0466
Mailing Address - Street 1:1401 US HIGHWAY 80 WEST
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-4127
Mailing Address - Country:US
Mailing Address - Phone:334-289-0466
Mailing Address - Fax:334-289-5588
Practice Address - Street 1:1401 US HIGHWAY 80 WEST
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-4127
Practice Address - Country:US
Practice Address - Phone:334-289-0466
Practice Address - Fax:334-289-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-773-TA-219152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529920020Medicaid
AL01D1083392OtherCLIA ID NUMBER
AL529920020Medicaid
AL5259550002Medicare NSC
U52984Medicare UPIN
ALJ923Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER