Healthcare Provider Details

I. General information

NPI: 1750457230
Provider Name (Legal Business Name): MITHRA JIGME GREEN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5267 GREENWICH RD SUITE 201
VIRGINIA BEACH VA
23462-6028
US

IV. Provider business mailing address

5267 GREENWICH RD SUITE 201
VIRGINIA BEACH VA
23462-6028
US

V. Phone/Fax

Practice location:
  • Phone: 757-313-6723
  • Fax: 757-313-4596
Mailing address:
  • Phone: 757-313-6723
  • Fax: 757-313-4596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104555605
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: