MEDICARE: SANDRA GREENE

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	251C00000X	Developmentally Disabled Services Day Training Agency		FL

General Provider Information

NPI Number	:	1619588845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA GREENE

Provider Business Mailing Address
First Line	:	6617 LETOHATCHEE ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-8029
Country	:	US
Telephone Number	:	185-086-6705
Fax Number	:

Provider Business Practice Location Address
First Line	:	6617 LETOHATCHEE ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-8029
Country	:	US
Telephone Number	:	185-086-6705
Fax Number	:

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

Provider Enumeration Date	:	08/12/2020
Last Update Date	:	08/12/2020

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Directions to “ SANDRA GREENE ” Practice Location

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