Provider Demographics
NPI:1417096256
Name:EVERGREEN NATURAL HEALTH SOLUTIONS
Entity type:Organization
Organization Name:EVERGREEN NATURAL HEALTH SOLUTIONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HALES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-895-8595
Mailing Address - Street 1:1640 W CHERRY LN
Mailing Address - Street 2:130
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1321
Mailing Address - Country:US
Mailing Address - Phone:208-895-8595
Mailing Address - Fax:208-895-8594
Practice Address - Street 1:1640 W CHERRY LN
Practice Address - Street 2:130
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1321
Practice Address - Country:US
Practice Address - Phone:208-895-8595
Practice Address - Fax:208-895-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1671661Medicare PIN
ID1366521Medicare PIN