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General NPI Number Information
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NPI Number | 1912582230
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Entity Type | Organization
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Legal Business Name | EVERGREEN THERAPEUTIC MASSAGE LLC
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Dates
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Enumeration Date | 03/17/2021
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Last Update Date | 03/17/2021
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Provider Practice Location Address
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Address Line | 1240 BERGEN PKWY STE A230-11
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City | EVERGREEN
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State | CO
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Zip | 80439-9524
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Country | US
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Telephone | 720-471-3043
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1571
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City | EVERGREEN
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State | CO
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Zip | 80437-1571
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PST
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Name | VERONIQUE HQ FOX
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Credential | BS, LMT, BCTMB
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Telephone | 720-471-3043
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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