Healthcare Provider Details

I. General information

NPI: 1700337714
Provider Name (Legal Business Name): TIMOTHY GREENE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 E WRENWOOD AVE APT 206
FRESNO CA
93710-6154
US

IV. Provider business mailing address

481 E WRENWOOD AVE APT 206
FRESNO CA
93710-6154
US

V. Phone/Fax

Practice location:
  • Phone: 559-301-9463
  • Fax:
Mailing address:
  • Phone: 559-301-9463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: