Provider Demographics
NPI:1356839575
Name:EVERGREEN HEALTH CENTER LLC
Entity Type:Organization
Organization Name:EVERGREEN HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CALILUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:671-488-8817
Mailing Address - Street 1:520 ROUTE 8
Mailing Address - Street 2:
Mailing Address - City:MAITE
Mailing Address - State:GU
Mailing Address - Zip Code:96910
Mailing Address - Country:US
Mailing Address - Phone:671-922-0118
Mailing Address - Fax:671-472-3981
Practice Address - Street 1:520 ROUTE 8
Practice Address - Street 2:
Practice Address - City:MAITE
Practice Address - State:GU
Practice Address - Zip Code:96910
Practice Address - Country:US
Practice Address - Phone:671-922-0118
Practice Address - Fax:671-477-2464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care