Provider Demographics
NPI:1639318413
Name:EVERGREEN PAIN MANAGEMENT & REHABILITATION LTD
Entity Type:Organization
Organization Name:EVERGREEN PAIN MANAGEMENT & REHABILITATION LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-240-9111
Mailing Address - Street 1:5445 DETROIT RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHEFFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44054-2904
Mailing Address - Country:US
Mailing Address - Phone:440-240-9111
Mailing Address - Fax:440-934-5459
Practice Address - Street 1:5445 DETROIT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44054-2904
Practice Address - Country:US
Practice Address - Phone:440-240-9111
Practice Address - Fax:440-934-5459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2954111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0100XChiropractic ProvidersChiropractorOccupational HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2085032Medicaid
OH123236700OtherFEDERAL WORKER'S COMPENSATION
OH000000324155OtherBCBS
OH=========OtherTAX ID
OH=========027OtherCARESOURCE
OHU90521Medicare UPIN