Healthcare Provider Details

I. General information

NPI: 1366354029
Provider Name (Legal Business Name): GREEN SPORTS MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7471 N FRESNO ST
FRESNO CA
93720-2457
US

IV. Provider business mailing address

2021 HERNDON AVE STE 201
CLOVIS CA
93611-6317
US

V. Phone/Fax

Practice location:
  • Phone: 559-813-3005
  • Fax:
Mailing address:
  • Phone: 559-387-5230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: SONYA LEAL
Title or Position: ADMIN
Credential:
Phone: 559-387-5230