Provider Demographics
NPI:1619096005
Name:EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
Entity Type:Organization
Organization Name:EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:503-704-5408
Mailing Address - Street 1:911 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1853
Mailing Address - Country:US
Mailing Address - Phone:503-765-5081
Mailing Address - Fax:971-316-1553
Practice Address - Street 1:8614 E MILL PLAIN BLVD STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2058
Practice Address - Country:US
Practice Address - Phone:360-213-2088
Practice Address - Fax:360-213-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602608675332B00000X, 332BC3200X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9059551Medicaid
WA5463340003Medicare NSC