Basic Information
| Provider Information | |||||||||
| NPI: | 1528729902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | LAVERDIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HERITAGE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481953094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347672250 | ||||||||
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| Address1: | 1 HERITAGE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481953094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347672250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2022 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | Y | Eye and Vision Services Providers | Technician/Technologist |
No ID Information.