MEDICARE: MIMOKA 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	164X00000X	Licensed Vocational Nurse	343789	TX

General Provider Information

NPI Number	:	1932680816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIMOKA GREEN

Provider Business Mailing Address
First Line	:	4410 OAK VISTA CIR
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-4616
Country	:	US
Telephone Number	:	318-792-7004
Fax Number	:

Provider Business Practice Location Address
First Line	:	2404 LIMESTONE TRL
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-8909
Country	:	US
Telephone Number	:	318-792-7004
Fax Number	:

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

Provider Enumeration Date	:	08/28/2018
Last Update Date	:	08/28/2018

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Directions to “ MIMOKA GREEN ” Practice Location

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