MEDICARE: LAKETA 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1902597057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKETA GREEN

Provider Business Mailing Address
First Line	:	7320 S RAINBOW BLVD # 102-192
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-0406
Country	:	US
Telephone Number	:	702-625-1079
Fax Number	:

Provider Business Practice Location Address
First Line	:	7320 S RAINBOW BLVD # 102-192
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-0406
Country	:	US
Telephone Number	:	702-625-1079
Fax Number	:

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

Provider Enumeration Date	:	05/18/2023
Last Update Date	:	06/10/2023

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Directions to “ LAKETA GREEN ” Practice Location

Language	Start Address	Practice Location

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