Provider Demographics
NPI:1215699715
Name:GREEN, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 SMART CLINIC
Mailing Address - Street 2:CAMP PENDLETON NORTH
Mailing Address - City:OCENANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:814-574-6049
Mailing Address - Fax:
Practice Address - Street 1:CAMP PENDLETON NORTH
Practice Address - Street 2:52 AREA SMART CLINIC
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058
Practice Address - Country:US
Practice Address - Phone:814-574-6049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist