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General NPI Number Information
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NPI Number | 1023295276
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Entity Type | Organization
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Legal Business Name | EVERGREEN WELLNESS CENTER INC.
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Dates
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Enumeration Date | 01/29/2008
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Last Update Date | 11/01/2016
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Provider Practice Location Address
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Address Line | 2950 LOS FELIZ BLVD 203
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City | LOS ANGELES
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State | CA
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Zip | 90039-1532
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Country | US
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Telephone | 323-665-1985
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Fax |
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Provider Business Mailing Address
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Address Line | 2950 LOS FELIZ BLVD 203
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City | LOS ANGELES
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State | CA
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Zip | 90039-1532
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Country | US
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Telephone | 323-665-1985
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOAN KIM-WAGNER
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Credential | ACUPUNCTURIST
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Telephone | 323-665-1985
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | AC9278
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License Number State | CA
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