Healthcare Provider Details

I. General information

NPI: 1114127214
Provider Name (Legal Business Name): MARC THOMAS GREEN SR. CERTIFIED PEER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 EAST PKWY STE 800
SACRAMENTO CA
95823-2501
US

IV. Provider business mailing address

7001 EAST PKWY STE 800
SACRAMENTO CA
95823-2501
US

V. Phone/Fax

Practice location:
  • Phone: 916-879-1043
  • Fax:
Mailing address:
  • Phone: 916-879-1043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-DPNCOE
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: