Healthcare Provider Details

I. General information

NPI: 1780568790
Provider Name (Legal Business Name): EVERGREEN FAMILY CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 PUTNAM PIKE UNIT 4
CHEPACHET RI
02814-1404
US

IV. Provider business mailing address

142 S MAIN ST
COVENTRY RI
02816-5729
US

V. Phone/Fax

Practice location:
  • Phone: 401-568-2200
  • 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: ANISSA BOUDREAU
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 401-301-4940