Provider Demographics
NPI:1295036291
Name:EVERGREEN ACUPUNCTURE
Entity Type:Organization
Organization Name:EVERGREEN ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:KYUNGAE
Authorized Official - Last Name:CHAE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, PHD
Authorized Official - Phone:201-945-0022
Mailing Address - Street 1:2083 CENTER AVE.
Mailing Address - Street 2:2A
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024
Mailing Address - Country:US
Mailing Address - Phone:201-945-0022
Mailing Address - Fax:877-371-3713
Practice Address - Street 1:2083 CENTER AVE.
Practice Address - Street 2:2A
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024
Practice Address - Country:US
Practice Address - Phone:201-945-0022
Practice Address - Fax:877-371-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-06
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00031800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty