MEDICARE: ED GREEN CHIROPRACTIC, A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	29791	CA

General Provider Information

NPI Number	:	1649537721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ED GREEN CHIROPRACTIC, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	301 SCIENCE DR
Second Line	:	#100
City	:	MOORPARK
State	:	CA
Zip	:	93021-2094
Country	:	US
Telephone Number	:	805-531-1188
Fax Number	:	805-531-1112

Provider Business Practice Location Address
First Line	:	301 SCIENCE DR
Second Line	:	#100
City	:	MOORPARK
State	:	CA
Zip	:	93021-2094
Country	:	US
Telephone Number	:	805-531-1188
Fax Number	:	805-531-1112

Authorized Official
Title or Position	:	CHIROPRACTOR/PRESIDENT
Name	:	DR. EDWARD GREEN
Credential	:	D.C, C.C.S.P
Telephone Number	:	805-531-1188

Provider Enumeration Date	:	04/13/2012
Last Update Date	:	06/15/2012

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