Healthcare Provider Details

I. General information

NPI: 1235411810
Provider Name (Legal Business Name): GREEN VI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 HAVENSIGHT PORT OF SALE, STE 15-16
ST THOMAS VI
00802
US

IV. Provider business mailing address

9100 HAVENSIGHT PORT OF SALE, STE 15-16
ST THOMAS VI
00802
US

V. Phone/Fax

Practice location:
  • Phone: 310-745-4787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number164
License Number StateVI

VIII. Authorized Official

Name: DR. CHRISTOPHER THOMAS REINBOLD
Title or Position: MEMBER
Credential: DPT
Phone: 310-745-4787