Provider Demographics
NPI:1811291305
Name:EVERGREEN MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:EVERGREEN MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MNGR.
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-415-8253
Mailing Address - Street 1:5944 CORAL RIDGE DR # 138
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3300
Mailing Address - Country:US
Mailing Address - Phone:954-415-8253
Mailing Address - Fax:
Practice Address - Street 1:5944 CORAL RIDGE DR # 138
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-3300
Practice Address - Country:US
Practice Address - Phone:954-415-8253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4871111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty