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General NPI Number Information
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NPI Number | 1639318413
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Entity Type | Organization
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Legal Business Name | EVERGREEN PAIN MANAGEMENT & REHABILITATION LTD
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Dates
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Enumeration Date | 02/18/2009
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 5445 DETROIT RD SUITE 201
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City | SHEFFIELD VILLAGE
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State | OH
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Zip | 44054-2904
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Country | US
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Telephone | 440-240-9111
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Fax | 440-934-5459
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Provider Business Mailing Address
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Address Line | 5445 DETROIT RD SUITE 201
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City | SHEFFIELD VILLAGE
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State | OH
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Zip | 44054-2904
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Country | US
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Telephone | 440-240-9111
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Fax | 440-934-5459
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Authorized Official
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Title or Position | OWNER
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Name | BRIAN L BENNETT
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Credential | D.C.
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Telephone | 440-240-9111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NX0100X
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Taxonomy Name | Occupational Health Chiropractor
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License Number | 2954
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License Number State | OH
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