Healthcare Provider Details

I. General information

NPI: 1861056228
Provider Name (Legal Business Name): LYDIA GREEN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W AVENUE J
LANCASTER CA
93534-2814
US

IV. Provider business mailing address

2851 W 120TH ST STE E-134
HAWTHORNE CA
90250-3395
US

V. Phone/Fax

Practice location:
  • Phone: 323-691-1772
  • Fax:
Mailing address:
  • Phone: 323-691-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: LYDIA GREEN
Title or Position: OWNER
Credential: MD
Phone: 323-691-1772