Provider Demographics
NPI:1447023049
Name:EVERGREEN CHINESE MEDICINE LLC
Entity type:Organization
Organization Name:EVERGREEN CHINESE MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:FANG
Authorized Official - Middle Name:
Authorized Official - Last Name:WAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-828-1166
Mailing Address - Street 1:10261 MEADOW MIST CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-2421
Mailing Address - Country:US
Mailing Address - Phone:719-828-1166
Mailing Address - Fax:
Practice Address - Street 1:5555 ERINDALE DR STE 107
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6964
Practice Address - Country:US
Practice Address - Phone:719-828-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2025-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty