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General NPI Number Information
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NPI Number | 1952766362
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Entity Type | Organization
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Legal Business Name | NATHAN GREEN O.D. P.C.
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Dates
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Enumeration Date | 12/30/2015
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Last Update Date | 12/30/2015
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Provider Practice Location Address
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Address Line | 241 W 2100 S
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City | SOUTH SALT LAKE
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State | UT
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Zip | 84115-1830
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Country | US
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Telephone | 801-401-1068
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Fax |
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Provider Business Mailing Address
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Address Line | 241 W 2100 S
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City | SOUTH SALT LAKE
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State | UT
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Zip | 84115-1830
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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 | PRESIDENT
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Name | DR. NATHAN RAY GREEN
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Credential | OD
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Telephone | 801-401-1068
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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 | 5340358-9934
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License Number State | UT
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