=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306281696
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN CHIROPRACTIC CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2013
-----------------------------------------------------
Last Update Date | 05/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 HAMRIC DR W
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36203-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-831-0334
-----------------------------------------------------
Fax | 256-831-0633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7751
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36203-7751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-831-0334
-----------------------------------------------------
Fax | 256-831-0633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEVEN BERT GREEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 256-831-0334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1552
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------