Provider Demographics
NPI:1457043119
Name:EVERGREEN MYOHABITS LLC
Entity Type:Organization
Organization Name:EVERGREEN MYOHABITS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MYOFUNCTIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIKHATSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:DENTAL HYGIENIST
Authorized Official - Phone:360-448-1830
Mailing Address - Street 1:701 NE 136TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 NE 136TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6937
Practice Address - Country:US
Practice Address - Phone:360-448-1830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty