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General NPI Number Information
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NPI Number | 1639971377
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Entity Type | Organization
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Legal Business Name | EVERGREEN WELLNESS ENDEAVORS LLC
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Dates
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Enumeration Date | 03/25/2025
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Last Update Date | 03/25/2025
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Provider Practice Location Address
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Address Line | 675 E ANTON ST
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City | MERIDIAN
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State | ID
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Zip | 83646-6298
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Country | US
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Telephone | 208-637-5102
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Fax |
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Provider Business Mailing Address
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Address Line | 675 E ANTON ST
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City | MERIDIAN
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State | ID
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Zip | 83646-6298
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Country | US
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Telephone | 208-637-5102
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Fax |
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Authorized Official
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Title or Position | OWNER/SOCIAL WORKER
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Name | MS. PATRICIA ELLIS
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Credential | LMSW
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Telephone | 208-637-5102
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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