Provider Demographics
NPI:1508196056
Name:GREEN, EDWARD B (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:B
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6789 N WILLOW AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5959
Mailing Address - Country:US
Mailing Address - Phone:559-298-6325
Mailing Address - Fax:
Practice Address - Street 1:6789 N WILLOW AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5959
Practice Address - Country:US
Practice Address - Phone:559-298-6325
Practice Address - Fax:559-298-6322
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29791111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician