1346840873 NPI number — EVERGREEN THERAPEUTIC, PLLC

Table of content: KALLE ELLEN LUNDEN NP (NPI 1306185293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346840873 NPI number — EVERGREEN THERAPEUTIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN THERAPEUTIC, PLLC
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:
Provider Other Organization Name Type Code:
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:
1346840873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27627-7501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-249-8675
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7427 OLD STAGE RD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGIER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27501-7401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-561-9663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BROADWELL
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
BENGTSON
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
919-561-9663

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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