Provider Demographics
NPI:1811402431
Name:EVERGREEN WELLNESS PARTNERS, LLC
Entity Type:Organization
Organization Name:EVERGREEN WELLNESS PARTNERS, LLC
Other - Org Name:EVERGREEN WELLNESS STUDIOS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:DAYE
Authorized Official - Last Name:DANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-895-8595
Mailing Address - Street 1:1710 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1340
Mailing Address - Country:US
Mailing Address - Phone:208-895-8595
Mailing Address - Fax:
Practice Address - Street 1:1710 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1340
Practice Address - Country:US
Practice Address - Phone:208-895-8595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty