Provider Demographics
NPI:1578831665
Name:EVERNORTH DIRECT HEALTH LLC
Entity Type:Organization
Organization Name:EVERNORTH DIRECT HEALTH LLC
Other - Org Name:MOHAWK HEALTHY LIFE CENTER - LYERLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:9276 SCRANTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-7701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5081 HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:LYERLY
Practice Address - State:GA
Practice Address - Zip Code:30730-4585
Practice Address - Country:US
Practice Address - Phone:800-241-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-05
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004110332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site