Provider Demographics
NPI:1396210563
Name:GREEN SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:GREEN SPORTS MEDICINE INC
Other - Org Name:GREEN SPORTS MEDICINE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-813-3005
Mailing Address - Street 1:7471 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2457
Mailing Address - Country:US
Mailing Address - Phone:559-981-5566
Mailing Address - Fax:559-228-9989
Practice Address - Street 1:2021 HERNDON AVE STE 201
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6101
Practice Address - Country:US
Practice Address - Phone:559-981-5566
Practice Address - Fax:559-228-9989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty