Healthcare Provider Details

I. General information

NPI: 1124220793
Provider Name (Legal Business Name): MATTHEW STUART GREEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6232 LA SALLE AVE
OAKLAND CA
94611-2804
US

IV. Provider business mailing address

6232 LA SALLE AVE
OAKLAND CA
94611-2804
US

V. Phone/Fax

Practice location:
  • Phone: 510-200-9000
  • Fax: 510-788-4034
Mailing address:
  • Phone: 510-200-9000
  • Fax: 510-788-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC28669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: