Provider Demographics
NPI:1235680828
Name:EVERGREEN NATUROPATHIC CLINIC LLC
Entity Type:Organization
Organization Name:EVERGREEN NATUROPATHIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:FOREST
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:971-313-2752
Mailing Address - Street 1:3689 CARMAN DR STE 300
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2620
Mailing Address - Country:US
Mailing Address - Phone:971-313-2752
Mailing Address - Fax:
Practice Address - Street 1:3689 CARMAN DR STE 300
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2620
Practice Address - Country:US
Practice Address - Phone:971-313-2752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1186R175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty