1568858363 NPI number — EVERGREEN MOUNTAINS THERAPY AND CONSULTING, LLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568858363 NPI number — EVERGREEN MOUNTAINS THERAPY AND CONSULTING, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN MOUNTAINS THERAPY AND CONSULTING, LLC.
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:
1568858363
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREGON CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97045-1032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-260-0969
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SANT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
503-260-0969

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  L6297 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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