Healthcare Provider Details

I. General information

NPI: 1043531676
Provider Name (Legal Business Name): MACK GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16008 KAMANA RD SUITE 100
APPLE VALLEY CA
92307-1376
US

IV. Provider business mailing address

12277 APPLE VALLEY RD PMB 288
APPLE VALLEY CA
92308-1701
US

V. Phone/Fax

Practice location:
  • Phone: 760-956-5200
  • Fax: 760-669-0793
Mailing address:
  • Phone: 760-956-5200
  • Fax: 760-669-0793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA1259029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: