Provider Demographics
NPI:1144081027
Name:GREENE, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7042 JANE PARKS WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3670
Mailing Address - Country:US
Mailing Address - Phone:612-747-2576
Mailing Address - Fax:612-926-2806
Practice Address - Street 1:7042 JANE PARKS WAY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3670
Practice Address - Country:US
Practice Address - Phone:612-747-2576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCVAN7065172A00000X
NC000048568756172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty