MEDICARE: GAVIN R GREEN MPT

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	225100000X	Physical Therapist	1263	NV

General Provider Information

NPI Number	:	1780621078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAVIN R GREEN MPT

Provider Business Mailing Address
First Line	:	801 S RANCHO DR
Second Line	:	STE F-4
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-3854
Country	:	US
Telephone Number	:	702-383-5115
Fax Number	:	702-678-6159

Provider Business Practice Location Address
First Line	:	801 S RANCHO DR
Second Line	:	STE F-4
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-3854
Country	:	US
Telephone Number	:	702-383-5115
Fax Number	:	702-678-6159

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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Directions to “ GAVIN R GREEN MPT” Practice Location

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