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
State | License ID | Taxonomies |
---|---|---|
NJ | 25MZ00031800 | 171100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 171100000X | Other Service Providers | Acupuncturist | Group - Multi-Specialty |