Healthcare Provider Details

I. General information

NPI: 1386610681
Provider Name (Legal Business Name): BART NELS GREEN DC, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10155 PACIFIC HEIGHTS BLVD BUILDING AZ, 2ND FLOOR
SAN DIEGO CA
92121
US

IV. Provider business mailing address

1507 E VALLEY PKWY #3-486
ESCONDIDO CA
92027-2322
US

V. Phone/Fax

Practice location:
  • Phone: 858-651-5918
  • Fax: 858-622-1658
Mailing address:
  • Phone: 858-208-8779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC22689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: