Provider Demographics
NPI:1831614361
Name:GREEN, LEE CLARK (EMT-B)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:CLARK
Last Name:GREEN
Suffix:
Gender:M
Credentials:EMT-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MANN RD LOT 141
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4271
Mailing Address - Country:US
Mailing Address - Phone:248-410-2793
Mailing Address - Fax:
Practice Address - Street 1:1410 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0046
Practice Address - Country:US
Practice Address - Phone:248-456-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-05
Last Update Date:2017-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3203058614146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic