Provider Demographics
NPI:1770267056
Name:GREEN, NATHAN LUKE
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:LUKE
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 1:20993 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:CRIDERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45806-3101
Mailing Address - Country:US
Mailing Address - Phone:419-371-7854
Mailing Address - Fax:
Practice Address - Street 1:20993 TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:CRIDERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45806-3101
Practice Address - Country:US
Practice Address - Phone:419-371-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171W00000XOther Service ProvidersContractor