Provider Demographics
NPI:1407044951
Name:EVERGREENE CENTER INC
Entity Type:Organization
Organization Name:EVERGREENE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-626-9021
Mailing Address - Street 1:8983 OKEECHOBEE BLVD
Mailing Address - Street 2:STE 202 NUMB 304
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-5115
Mailing Address - Country:US
Mailing Address - Phone:561-626-9021
Mailing Address - Fax:561-626-7593
Practice Address - Street 1:1035 S STATE ROAD 7
Practice Address - Street 2:STE C214
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6134
Practice Address - Country:US
Practice Address - Phone:561-626-9021
Practice Address - Fax:561-626-7593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN