Healthcare Provider Details

I. General information

NPI: 1649768748
Provider Name (Legal Business Name): EVERGREEN SPINE & REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 EVERGREEN PL STE 501
EAST ORANGE NJ
07018-2010
US

IV. Provider business mailing address

134 EVERGREEN PL STE 501
EAST ORANGE NJ
07018-2010
US

V. Phone/Fax

Practice location:
  • Phone: 973-678-7833
  • Fax: 973-678-7839
Mailing address:
  • Phone: 973-678-7833
  • Fax: 973-678-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00451300
License Number StateNJ

VIII. Authorized Official

Name: DR. STEPHEN BERGER
Title or Position: OWNER
Credential: DC
Phone: 973-678-7833