Provider Demographics
NPI:1780621078
Name:GREEN, GAVIN R (MPT)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:R
Last Name:GREEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S RANCHO DR
Mailing Address - Street 2:STE F-4
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3854
Mailing Address - Country:US
Mailing Address - Phone:702-383-5115
Mailing Address - Fax:702-678-6159
Practice Address - Street 1:801 S RANCHO DR
Practice Address - Street 2:STE F-4
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3854
Practice Address - Country:US
Practice Address - Phone:702-383-5115
Practice Address - Fax:702-678-6159
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV101268Medicare ID - Type Unspecified