Healthcare Provider Details

I. General information

NPI: 1760708648
Provider Name (Legal Business Name): MRS. LATONYA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. LATONYA GREEN

II. Dates (important events)

Enumeration Date: 04/16/2010
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 LINDEN DR
ARLINGTON TX
76017-4637
US

IV. Provider business mailing address

3902 LINDEN DR
ARLINGTON TX
76017-4637
US

V. Phone/Fax

Practice location:
  • Phone: 972-660-1920
  • Fax: 817-563-1272
Mailing address:
  • Phone: 972-660-1920
  • Fax: 817-563-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number725107
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: