Healthcare Provider Details

I. General information

NPI: 1194101816
Provider Name (Legal Business Name): MRS. LATRESHA EVANS GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 DRIFTWOOD LN
BIRMINGHAM AL
35235-2981
US

IV. Provider business mailing address

PO BOX 610114
BIRMINGHAM AL
35261-0114
US

V. Phone/Fax

Practice location:
  • Phone: 205-706-3012
  • Fax:
Mailing address:
  • Phone: 205-706-3012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: