MEDICARE: GINA GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT009291	GA

General Provider Information

NPI Number	:	1497209670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA GREEN

Provider Business Mailing Address
First Line	:	850 ROCK SHOALS CT
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-7332
Country	:	US
Telephone Number	:	404-994-7727
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 ROCK SHOALS CT
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-7332
Country	:	US
Telephone Number	:	404-994-7727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2016
Last Update Date	:	08/08/2016

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Directions to “ GINA GREEN ” Practice Location

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