Healthcare Provider Details

I. General information

NPI: 1548959737
Provider Name (Legal Business Name): EVERGREEN CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3454 RICE ST
SAINT PAUL MN
55126-3044
US

IV. Provider business mailing address

3454 RICE ST
SAINT PAUL MN
55126-3044
US

V. Phone/Fax

Practice location:
  • Phone: 651-483-4321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: ANDREAS EZER
Title or Position: OWNER/CHIROPRACTOR
Credential: DC
Phone: 715-216-5961