MEDICARE: NATHAN GREEN O.D. P.C.

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	5340358-9934	UT

General Provider Information

NPI Number	:	1952766362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATHAN GREEN O.D. P.C.

Provider Business Mailing Address
First Line	:	241 W 2100 S
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-1830
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	241 W 2100 S
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-1830
Country	:	US
Telephone Number	:	801-401-1068
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NATHAN RAY GREEN
Credential	:	OD
Telephone Number	:	801-401-1068

Provider Enumeration Date	:	12/30/2015
Last Update Date	:	12/30/2015

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