Provider Demographics
NPI:1407237175
Name:EVERGREEN INTEGRATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:EVERGREEN INTEGRATIVE MEDICINE, LLC
Other - Org Name:NW FUNCTIONAL THYROID CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SOSZKA
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:503-388-6715
Mailing Address - Street 1:4926 SE WOODSTOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6163
Mailing Address - Country:US
Mailing Address - Phone:503-388-6715
Mailing Address - Fax:888-302-5652
Practice Address - Street 1:4926 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6163
Practice Address - Country:US
Practice Address - Phone:503-388-6715
Practice Address - Fax:888-302-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1333261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275019Medicaid