Provider Demographics
NPI:1043026537
Name:GREEN, RAYMOND DEWAYNE
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:DEWAYNE
Last Name:GREEN
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 1:1510 LITTLE HORSE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JULIAN
Mailing Address - State:WV
Mailing Address - Zip Code:25529-9621
Mailing Address - Country:US
Mailing Address - Phone:304-542-2744
Mailing Address - Fax:
Practice Address - Street 1:1510 LITTLE HORSE CREEK RD
Practice Address - Street 2:
Practice Address - City:JULIAN
Practice Address - State:WV
Practice Address - Zip Code:25529-9621
Practice Address - Country:US
Practice Address - Phone:304-542-2744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant