Healthcare Provider Details

I. General information

NPI: 1235601055
Provider Name (Legal Business Name): JONATHAN CARSON GREEN LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MAIN ST
DANVILLE IN
46122-1948
US

IV. Provider business mailing address

6905 S RACEWAY RD
CAMBY IN
46113-9290
US

V. Phone/Fax

Practice location:
  • Phone: 317-745-4451
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001959A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: