Basic Information
| Provider Information | |||||||||
| NPI: | 1396210563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREEN SPORTS MEDICINE INC | ||||||||
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| OtherOrganizationName: | GREEN SPORTS MEDICINE, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7471 N FRESNO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599815566 | ||||||||
| FaxNumber: | 5592289989 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 HERNDON AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936116101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599815566 | ||||||||
| FaxNumber: | 5592289989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2018 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | ERICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 5598133005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207QS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.