MEDICARE: GREEN THERAPEUTIC MASSAGE

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
1	175F00000X	Naturopath	14122	NC

General Provider Information

NPI Number	:	1376093203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN THERAPEUTIC MASSAGE

Provider Business Mailing Address
First Line	:	7406 CHAPEL HILL RD
Second Line	:	SUITE K
City	:	RALEIGH
State	:	NC
Zip	:	27607
Country	:	US
Telephone Number	:	919-813-0978
Fax Number	:	919-800-3344

Provider Business Practice Location Address
First Line	:	7406 CHAPEL HILL RD
Second Line	:	SUITE K
City	:	RALEIGH
State	:	NC
Zip	:	27607-5077
Country	:	US
Telephone Number	:	919-813-0978
Fax Number	:	919-800-3344

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT VINCENT GREEN
Credential	:	LMBT
Telephone Number	:	919-813-0978

Provider Enumeration Date	:	10/04/2016
Last Update Date	:	10/04/2016

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