Healthcare Provider Details

I. General information

NPI: 1326022344
Provider Name (Legal Business Name): CAROL MYRTLE GREEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3541 RANDOLPH RD STE 100W
CHARLOTTE NC
28211-1082
US

IV. Provider business mailing address

4601 PARK RD SUITE 300
CHARLOTTE NC
28209-3239
US

V. Phone/Fax

Practice location:
  • Phone: 704-323-2000
  • Fax:
Mailing address:
  • Phone: 704-323-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3345
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: