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General NPI Number Information
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NPI Number | 1043531676
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Entity Type | Individual
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Provider Name | MACK GREEN MD
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Gender | Male
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Dates
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Enumeration Date | 06/17/2010
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Last Update Date | 09/28/2015
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Provider Practice Location Address
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Address Line | 16008 KAMANA RD SUITE 100
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City | APPLE VALLEY
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State | CA
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Zip | 92307-1376
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Country | US
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Telephone | 760-956-5200
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Fax | 760-669-0793
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Provider Business Mailing Address
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Address Line | 12277 APPLE VALLEY RD PMB 288
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City | APPLE VALLEY
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State | CA
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Zip | 92308-1701
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Country | US
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Telephone | 760-956-5200
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Fax | 760-669-0793
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | A1259029
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License Number State | CA
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