Provider Demographics
NPI:1902342165
Name:GREEN, MARK (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 COWEETA TER
Mailing Address - Street 2:
Mailing Address - City:OTTO
Mailing Address - State:NC
Mailing Address - Zip Code:28763-8141
Mailing Address - Country:US
Mailing Address - Phone:828-371-1010
Mailing Address - Fax:
Practice Address - Street 1:339 NACOOCHEE DR
Practice Address - Street 2:
Practice Address - City:RABUN GAP
Practice Address - State:GA
Practice Address - Zip Code:30568-2200
Practice Address - Country:US
Practice Address - Phone:706-746-7725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0022502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer