MEDICARE: KRISTEN HILLARY GREEN O.D.

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	152W00000X	Optometrist	2774694-9934	UT

General Provider Information

NPI Number	:	1720116387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN HILLARY GREEN O.D.

Provider Business Mailing Address
First Line	:	228 RAMONA AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2115
Country	:	US
Telephone Number	:	801-661-8759
Fax Number	:

Provider Business Practice Location Address
First Line	:	7025 PARK CENTRE DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-6619
Country	:	US
Telephone Number	:	801-233-9334
Fax Number	:	801-233-9325

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

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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