Provider Demographics
NPI:1720867047
Name:EVERGREEN CHIROPRACTIC SC
Entity Type:Organization
Organization Name:EVERGREEN CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ELYSE
Authorized Official - Last Name:EBERLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-295-6681
Mailing Address - Street 1:N67W5486 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2126
Mailing Address - Country:US
Mailing Address - Phone:815-291-6681
Mailing Address - Fax:
Practice Address - Street 1:W61N512 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-1926
Practice Address - Country:US
Practice Address - Phone:262-421-6155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty