Provider Demographics
NPI:1982366613
Name:GREEN, LAVON CHERALE (PROSTHETICSPECIALIST)
Entity Type:Individual
Prefix:
First Name:LAVON
Middle Name:CHERALE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PROSTHETICSPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71711-0444
Mailing Address - Country:US
Mailing Address - Phone:870-675-1246
Mailing Address - Fax:
Practice Address - Street 1:124 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-4010
Practice Address - Country:US
Practice Address - Phone:870-675-1246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR444101744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management