Healthcare Provider Details

I. General information

NPI: 1831614361
Provider Name (Legal Business Name): LEE CLARK GREEN EMT-B
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2017
Last Update Date: 08/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 S TELEGRAPH RD
BLOOMFIELD HILLS MI
48302-0046
US

IV. Provider business mailing address

2500 MANN RD LOT 141
CLARKSTON MI
48346-4271
US

V. Phone/Fax

Practice location:
  • Phone: 248-456-8150
  • Fax:
Mailing address:
  • Phone: 248-410-2793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number3203058614
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: