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General NPI Number Information
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NPI Number | 1598742827
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Entity Type | Individual
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Provider Name | GLENN D GREEN O.D.
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Gender | Male
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Dates
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Enumeration Date | 12/28/2005
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Last Update Date | 10/15/2024
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Provider Practice Location Address
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Address Line | 3882 N FOXTAIL RD
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City | POST FALLS
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State | ID
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Zip | 83854-0264
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Country | US
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Telephone | 360-739-6887
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Fax | 208-457-7008
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Provider Business Mailing Address
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Address Line | 3882 N FOXTAIL RD
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City | POST FALLS
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State | ID
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Zip | 83854-0264
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Country | US
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Telephone | 360-739-6887
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Fax | 208-457-7008
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OD00001910
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | ODP-100616
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License Number State | ID
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