=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396621017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MATTHEW ALAN GREENE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2025
-----------------------------------------------------
Last Update Date | 08/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3551 CAMINO MIRA COSTA # K-1
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-292-0460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3551 CAMINO MIRA COSTA # K-1
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-292-0460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC10236
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------