Provider Demographics
NPI:1093255127
Name:EVERGREEN LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:EVERGREEN LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZZELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-607-9511
Mailing Address - Street 1:32000 WOODWARD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0998
Mailing Address - Country:US
Mailing Address - Phone:248-838-3195
Mailing Address - Fax:
Practice Address - Street 1:32000 WOODWARD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0998
Practice Address - Country:US
Practice Address - Phone:248-838-3195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010513111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty