Provider Demographics
NPI:1649537721
Name:ED GREEN CHIROPRACTIC, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ED GREEN CHIROPRACTIC, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:805-531-1188
Mailing Address - Street 1:301 SCIENCE DR
Mailing Address - Street 2:#100
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2094
Mailing Address - Country:US
Mailing Address - Phone:805-531-1188
Mailing Address - Fax:805-531-1112
Practice Address - Street 1:301 SCIENCE DR
Practice Address - Street 2:#100
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-2094
Practice Address - Country:US
Practice Address - Phone:805-531-1188
Practice Address - Fax:805-531-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29791261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty