Healthcare Provider Details

I. General information

NPI: 1043651136
Provider Name (Legal Business Name): ARIEL MARGAURITE GREENE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

IV. Provider business mailing address

1393 BIG WOODS STARKS RD
VINTON LA
70668-5205
US

V. Phone/Fax

Practice location:
  • Phone: 337-721-7236
  • Fax:
Mailing address:
  • Phone: 337-853-2329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.200261
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: