Provider Demographics
NPI:1811266927
Name:GREEN, CHARLES PERRY
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PERRY
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 1:3361 NO KID RD
Mailing Address - Street 2:
Mailing Address - City:KAMIAH
Mailing Address - State:ID
Mailing Address - Zip Code:83536-5002
Mailing Address - Country:US
Mailing Address - Phone:208-553-0284
Mailing Address - Fax:208-935-2329
Practice Address - Street 1:3361 NO KID RD
Practice Address - Street 2:
Practice Address - City:KAMIAH
Practice Address - State:ID
Practice Address - Zip Code:83536-5002
Practice Address - Country:US
Practice Address - Phone:208-553-0284
Practice Address - Fax:208-935-2329
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID003866467172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker