Healthcare Provider Details

I. General information

NPI: 1205123031
Provider Name (Legal Business Name): DONALD JAMES GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 SAINT JOHN ST
PORTLAND ME
04102-3019
US

IV. Provider business mailing address

PO BOX 341
SACO ME
04072-0341
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-9660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: