MEDICARE: EVERGREEN NATURAL HEALING ACUPUNCTURE AND WELLNESS CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist
2	171100000X	Acupuncturist

General Provider Information

NPI Number	:	1790443539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN NATURAL HEALING ACUPUNCTURE AND WELLNESS CLINIC LLC

Provider Business Mailing Address
First Line	:	440 COBIA DR STE 1104
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-7159
Country	:	US
Telephone Number	:	832-866-2501
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 COBIA DR STE 1104
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-7159
Country	:	US
Telephone Number	:	832-866-2501
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DONG CAO
Credential	:
Telephone Number	:	832-866-2501

Provider Enumeration Date	:	11/29/2021
Last Update Date	:	06/12/2024

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