MEDICARE: EBONY L GREEN

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	225700000X	Massage Therapist	21539	NC

General Provider Information

NPI Number	:	1578411500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY L GREEN

Provider Business Mailing Address
First Line	:	620 OLD 30 RD APT 3
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-9751
Country	:	US
Telephone Number	:	910-382-5112
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 OLD 30 RD APT 3
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-9751
Country	:	US
Telephone Number	:	910-382-5112
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2026
Last Update Date	:	03/17/2026

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Directions to “ EBONY L GREEN ” Practice Location

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