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NPI Code Detail

MEDICARE: MR. ALEXANDER RYAN GREEN ATC, LAT

MEDICARE: MR. ALEXANDER RYAN GREEN ATC, LAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic TrainerAL4493FL
22255A2300XAthletic TrainerAT1168KY

General Provider Information

NPI Number : 1255784039
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ALEXANDER RYAN GREEN ATC, LAT
Provider Business Mailing Address
First Line : 1320 SW 82ND TER
Second Line : APT 423
City : PLANTATION
State : FL
Zip : 33324-3251
Country : US
Telephone Number : 610-392-9785
Fax Number :
Provider Business Practice Location Address
First Line : 7500 SW 30TH ST
Second Line :
City : DAVIE
State : FL
Zip : 33314-1020
Country : US
Telephone Number : 610-392-9785
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/18/2016
Last Update Date : 07/18/2016

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