Healthcare Provider Details

I. General information

NPI: 1073810453
Provider Name (Legal Business Name): GREENLINE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2011
Last Update Date: 02/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 BOMBAY LN
ROSWELL GA
30076-5819
US

IV. Provider business mailing address

804 BOMBAY LN
ROSWELL GA
30076-5819
US

V. Phone/Fax

Practice location:
  • Phone: 770-754-9880
  • Fax: 770-754-9881
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number058478
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number058478
License Number StateGA

VIII. Authorized Official

Name: DR. KIMBERLY GREEN
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 770-754-9880