Provider Demographics
NPI:1912582230
Name:EVERGREEN THERAPEUTIC MASSAGE LLC
Entity type:Organization
Organization Name:EVERGREEN THERAPEUTIC MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PST
Authorized Official - Prefix:
Authorized Official - First Name:VERONIQUE
Authorized Official - Middle Name:HQ
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:BS, LMT, BCTMB
Authorized Official - Phone:720-471-3043
Mailing Address - Street 1:PO BOX 1571
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80437-1571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 BERGEN PKWY STE A230-11
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-9524
Practice Address - Country:US
Practice Address - Phone:720-471-3043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty