Healthcare Provider Details

I. General information

NPI: 1194994350
Provider Name (Legal Business Name): RICHARD S. GREEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13210 SE 240TH ST STE C2
KENT WA
98042-5182
US

IV. Provider business mailing address

13210 SE 240TH ST STE C2
KENT WA
98042-5182
US

V. Phone/Fax

Practice location:
  • Phone: 253-631-1530
  • Fax: 253-631-5262
Mailing address:
  • Phone: 253-631-1530
  • Fax: 253-631-5262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD S GREEN
Title or Position: OWNER
Credential: O.D.
Phone: 253-631-1530