Provider Demographics
NPI:1871897744
Name:EVERGREEN CHIROPRACTIC
Entity type:Organization
Organization Name:EVERGREEN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUNG TAO
Authorized Official - Middle Name:DYLAN
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:682-325-4193
Mailing Address - Street 1:710 CENTERPARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2848
Mailing Address - Country:US
Mailing Address - Phone:682-325-4193
Mailing Address - Fax:682-325-4194
Practice Address - Street 1:710 CENTERPARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-2848
Practice Address - Country:US
Practice Address - Phone:682-325-4193
Practice Address - Fax:682-325-4194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty