Healthcare Provider Details

I. General information

NPI: 1760083885
Provider Name (Legal Business Name): GREEN CHIROPRACTIC & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22780 THREE NOTCH RD
LEXINGTON PARK MD
20653-1538
US

IV. Provider business mailing address

22780 THREE NOTCH RD
LEXINGTON PARK MD
20653-1538
US

V. Phone/Fax

Practice location:
  • Phone: 301-737-0662
  • Fax: 301-737-0675
Mailing address:
  • Phone: 301-737-0662
  • Fax: 301-737-0675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB GREEN
Title or Position: OWNER
Credential: DC
Phone: 301-737-0662