Healthcare Provider Details

I. General information

NPI: 1467803221
Provider Name (Legal Business Name): CHAYA S GREEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 BLUE DIAMOND RD STE 100
LAS VEGAS NV
89139-7787
US

IV. Provider business mailing address

8402 CENTENNIAL PKWY STE 240
LAS VEGAS NV
89149-4793
US

V. Phone/Fax

Practice location:
  • Phone: 702-443-9301
  • Fax: 702-342-0600
Mailing address:
  • Phone: 702-294-7499
  • Fax: 702-294-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.022522
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4726
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: