Healthcare Provider Details

I. General information

NPI: 1497464804
Provider Name (Legal Business Name): BRANDON PHILLIP GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24491 ALICIA PKWY
MISSION VIEJO CA
92691-4506
US

IV. Provider business mailing address

53 SANCTUARY LN
MISSION VIEJO CA
92692-5999
US

V. Phone/Fax

Practice location:
  • Phone: 949-876-5299
  • Fax:
Mailing address:
  • Phone: 510-828-7183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number303159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: