Healthcare Provider Details

I. General information

NPI: 1952606659
Provider Name (Legal Business Name): CRYSTAL M GREEN DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL M WOODBURY

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 SHERMAN AVE
SAINT JOSEPH MO
64506-3649
US

IV. Provider business mailing address

3949 SHERMAN AVE
SAINT JOSEPH MO
64506-3649
US

V. Phone/Fax

Practice location:
  • Phone: 816-387-8994
  • Fax: 816-387-8220
Mailing address:
  • Phone: 816-387-8994
  • Fax: 816-387-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2011000648
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2011000648
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number2011000648
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: