NPIMap

Organization Active NPI

Evergreen Integrative Medicine, LLC

  • Health Service Clinic/Center
  • Portland, OR
National Provider Identifier
1407237175
Registry record updated Mar 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Health Service Clinic/CenterTaxonomy code 261QH0100X
License
1333 Issued in OR
Legal business name
EVERGREEN INTEGRATIVE MEDICINE, LLC
Doing business as
NW Functional Thyroid Clinic
Practice address
4926 SE Woodstock Blvd
Portland, OR 97206-6163
Phone
(503) 388-6715
Fax
(888) 302-5652
NPI assigned
Jun 17, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 24, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Shawn Scott Soszka, ND, LACNPI 1649228636
Title
Member/Manager
Phone
(503) 388-6715

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Health Service Clinic/Center 261QH0100X 1333 OR Primary

Addresses

Primary practice location

4926 SE Woodstock Blvd
Portland, OR 97206-6163

Mailing address

4926 SE Woodstock Blvd
Portland, OR 97206-6163
Phone (503) 388-6715

Other identifiers 1

IdentifierTypeStateIssuer
275019MedicaidOR

Other names 1

  • NW Functional Thyroid Clinic Doing business as

National Provider Directory

National Provider Directory

Locations

7215 SE 13th Ave
Portland, OR 97202
Phone (503) 238-7025

4926 SE Woodstock Blvd
Portland, OR 97206
Phone (503) 388-6715

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1434499200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1648080000000",
    "number": "1407237175",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4926 SE WOODSTOCK BLVD",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972066163",
            "telephone_number": "503-388-6715",
            "fax_number": "888-302-5652"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4926 SE WOODSTOCK BLVD",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972066163",
            "telephone_number": "503-388-6715",
            "fax_number": "888-302-5652"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN INTEGRATIVE MEDICINE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-17",
        "last_updated": "2022-03-24",
        "certification_date": "2022-03-24",
        "status": "A",
        "authorized_official_last_name": "SOSZKA",
        "authorized_official_first_name": "SHAWN",
        "authorized_official_middle_name": "SCOTT",
        "authorized_official_title_or_position": "MEMBER/MANAGER",
        "authorized_official_telephone_number": "503-388-6715",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "ND, LAC"
    },
    "taxonomies": [
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": "OR",
            "license": "1333",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "275019",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NW Functional Thyroid Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.