Healthcare Provider Details

I. General information

NPI: 1891509386
Provider Name (Legal Business Name): OMAR GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 FULTON INDUSTRIAL BLVD SW
ATLANTA GA
30336-2659
US

IV. Provider business mailing address

950 DANNON VW SW STE 4103
ATLANTA GA
30331-2159
US

V. Phone/Fax

Practice location:
  • Phone: 404-346-3471
  • Fax:
Mailing address:
  • Phone: 404-433-7949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: