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Individual
DALE GREEN
Active
Individual
DALE GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT19251
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CK583Z
MEDICARE PTAN INDIVIDUAL
CA
Enumeration date
07/24/2009
Last updated
09/03/2018
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