Healthcare Provider Details

I. General information

NPI: 1902791031
Provider Name (Legal Business Name): EVERGREEN HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11528 LOUVRE PT
PEYTON CO
80831-8225
US

IV. Provider business mailing address

11528 LOUVRE PT
PEYTON CO
80831-8225
US

V. Phone/Fax

Practice location:
  • Phone: 304-860-2012
  • Fax:
Mailing address:
  • Phone: 304-860-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GREEN
Title or Position: PROVIDER
Credential: FNP-C
Phone: 304-860-2012