Healthcare Provider Details

I. General information

NPI: 1497919005
Provider Name (Legal Business Name): MARK A GREENE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 SW 73RD ST
OCALA FL
34476-5568
US

IV. Provider business mailing address

PO BOX 770666
OCALA FL
34477-0666
US

V. Phone/Fax

Practice location:
  • Phone: 352-237-5455
  • Fax: 352-237-5455
Mailing address:
  • Phone: 352-237-5455
  • Fax: 352-237-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA31236
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: