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General NPI Number Information
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NPI Number | 1689901803
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Entity Type | Individual
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Provider Name | AMBROSE GREEN JR. MOT
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Gender | Male
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Dates
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Enumeration Date | 11/09/2009
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Last Update Date | 11/09/2009
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Provider Practice Location Address
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Address Line | 35431 AVALON
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City | ROMULUS
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State | MI
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Zip | 48174
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Country | US
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Telephone | 734-262-4576
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Fax | 734-721-7009
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Provider Business Mailing Address
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Address Line | 35431 AVALON ST
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City | ROMULUS
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State | MI
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Zip | 48174-1724
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Country | US
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Telephone | 734-262-4576
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Fax | 734-721-7009
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 5201007262
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 2776
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License Number State | AL
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