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General NPI Number Information
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NPI Number | 1861195703
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Entity Type | Individual
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Provider Name | EDMUND GREEN LMT
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Gender | Male
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Dates
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Enumeration Date | 03/22/2023
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Last Update Date | 03/22/2023
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Provider Practice Location Address
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Address Line | 8500 STATION ST STE 300D
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City | MENTOR
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State | OH
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Zip | 44060-4963
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Country | US
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Telephone | 216-849-1079
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Fax | 888-312-2672
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Provider Business Mailing Address
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Address Line | 3522 W 127TH ST
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City | CLEVELAND
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State | OH
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Zip | 44111-3502
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Country | US
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Telephone |
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Fax |
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 33.021189
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License Number State | OH
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