Healthcare Provider Details

I. General information

NPI: 1174704738
Provider Name (Legal Business Name): DALE L GREEN LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 SAINT CHARLES WAY STE 200
YORK PA
17402-4661
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-851-5503
  • Fax: 717-851-5507
Mailing address:
  • Phone: 717-851-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN002407
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: