Provider Demographics
NPI:1316103864
Name:EVERGREEN CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:EVERGREEN CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOULTRIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-224-2279
Mailing Address - Street 1:1445 N 1200 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2449
Mailing Address - Country:US
Mailing Address - Phone:801-224-2279
Mailing Address - Fax:801-224-2381
Practice Address - Street 1:1445 N 1200 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2449
Practice Address - Country:US
Practice Address - Phone:801-224-2279
Practice Address - Fax:801-224-2381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5289181-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty