Provider Demographics
NPI:1568434025
Name:EVERGREEN DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:EVERGREEN DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-229-3301
Mailing Address - Street 1:2570 NW EDENBOWER BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-229-3311
Mailing Address - Fax:541-229-3327
Practice Address - Street 1:2570 NW EDENBOWER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6220
Practice Address - Country:US
Practice Address - Phone:541-229-3311
Practice Address - Fax:541-229-3327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213560Medicaid
ORJ8799-01OtherGROUP PACIFIC SOURCE
OR610550200OtherGROUP OWCP
OR845023000OtherGROUP BLUE CROSS
OR610550200OtherGROUP OWCP