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General NPI Number Information
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NPI Number | 1760206197
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Entity Type | Organization
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Legal Business Name | EVERGREEN FUNCTIONAL MEDICINE LLC
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Dates
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Enumeration Date | 11/12/2024
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 607 W WILLAPA AVE
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City | SPOKANE
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State | WA
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Zip | 99224-5337
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Country | US
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Telephone | 509-720-6314
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Fax |
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Provider Business Mailing Address
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Address Line | 607 W WILLAPA AVE
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City | SPOKANE
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State | WA
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Zip | 99224-5337
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Country | US
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Telephone | 509-720-6314
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR/ACCESS MANAGER
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Name | MS. JANE COX
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Credential |
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Telephone | 949-664-2796
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835N1003X
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Taxonomy Name | Nutrition Support Pharmacist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number |
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License Number State |
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