Healthcare Provider Details

I. General information

NPI: 1366426421
Provider Name (Legal Business Name): GARTH A GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 TORRANCE BLVD
TORRANCE CA
90503
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051
US

V. Phone/Fax

Practice location:
  • Phone: 310-750-1715
  • Fax: 310-792-6551
Mailing address:
  • Phone: 626-775-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA51547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: