Provider Demographics
NPI:1649768748
Name:EVERGREEN SPINE & REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN SPINE & REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-678-7833
Mailing Address - Street 1:134 EVERGREEN PL STE 501
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2010
Mailing Address - Country:US
Mailing Address - Phone:973-678-7833
Mailing Address - Fax:973-678-7839
Practice Address - Street 1:134 EVERGREEN PL STE 501
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2010
Practice Address - Country:US
Practice Address - Phone:973-678-7833
Practice Address - Fax:973-678-7839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00451300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty