Healthcare Provider Details

I. General information

NPI: 1255145819
Provider Name (Legal Business Name): EVERGREEN HOLISTIC HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

415 N FRONT ST
SPOONER WI
54801-1403
US

IV. Provider business mailing address

415 N FRONT ST
SPOONER WI
54801-1403
US

V. Phone/Fax

Practice location:
  • Phone: 715-544-8964
  • Fax:
Mailing address:
  • Phone: 715-544-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PARKER HEWES
Title or Position: BUSINESS MANAGER
Credential:
Phone: 715-544-8964