Healthcare Provider Details

I. General information

NPI: 1104358233
Provider Name (Legal Business Name): CHARMAINE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 MANOR PLAZA
PACIFICA CA
94044
US

IV. Provider business mailing address

480 MANOR PLAZA
PACIFICA CA
94044
US

V. Phone/Fax

Practice location:
  • Phone: 650-355-8787
  • Fax: 650-355-8780
Mailing address:
  • Phone: 650-355-8787
  • Fax: 650-355-8780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: