Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 104902 | MO |
N | 225100000X | Physical Therapist | 1101879 | KS |
N | 2251S0007X | Physical Therapist - Sports | 104902 | MO |
NPI | 1073554986 |
---|---|
Provider Name | Mr. Charles Henry Greene III |
First Address | Albany, MO 64402-1618 |
Second Address | Albany, MO 64402-1618 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
25783024 | BLUE CROSS BLUE SHIELD (01) | MO |