1003423914 NPI number — EVERGREEN CHIROPRACTIC PC

Table of content: (NPI 1003423914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003423914 NPI number — EVERGREEN CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN CHIROPRACTIC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERGREEN CHIROPRACTIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003423914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5920 BURMA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-3240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-330-8017
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
657 NE HOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-7328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-912-1156
Provider Business Practice Location Address Fax Number:
971-292-2932
Provider Enumeration Date:
09/24/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MANNS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
JARED
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
503-912-1156

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)