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General NPI Number Information
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NPI Number | 1801561634
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Entity Type | Organization
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Legal Business Name | EVERGREEN OPTOMETRY, PLLC
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Dates
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Enumeration Date | 08/13/2021
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Last Update Date | 03/30/2022
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Provider Practice Location Address
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Address Line | 15 SPECTRUM LOOP SUITE 125
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City | COLORADO SPRINGS
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State | CO
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Zip | 80921
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Country | US
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Telephone | 719-661-0287
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 63780
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City | COLORADO SPRINGS
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State | CO
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Zip | 80962-3780
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Country | US
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Telephone | 719-403-0991
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DR. CHELSEY BREANNE NOLASCO
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Credential | OD
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Telephone | 719-403-0991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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