Provider Demographics
NPI:1578707386
Name:EVERGREEN EYEWEAR
Entity Type:Organization
Organization Name:EVERGREEN EYEWEAR
Other - Org Name:EVERGREEN EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CPRP
Authorized Official - Phone:541-485-6340
Mailing Address - Street 1:2145 CENTENNIAL PLZ
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2421
Mailing Address - Country:US
Mailing Address - Phone:541-342-2020
Mailing Address - Fax:541-345-9218
Practice Address - Street 1:82B CENTENNIAL LOOP
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7909
Practice Address - Country:US
Practice Address - Phone:541-780-6300
Practice Address - Fax:541-345-9218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAUREL HILL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-23
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR162991156FX1800X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR079202Medicaid