Provider Demographics
NPI:1467530634
Name:EVERGREEN MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-590-1821
Mailing Address - Street 1:9442 GARDEN GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1453
Mailing Address - Country:US
Mailing Address - Phone:714-590-1821
Mailing Address - Fax:714-590-1591
Practice Address - Street 1:9442 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1453
Practice Address - Country:US
Practice Address - Phone:714-590-1821
Practice Address - Fax:714-590-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03020FMedicaid
CA1208900001Medicare ID - Type UnspecifiedMEDICARE