Provider Demographics
NPI:1619445657
Name:OREGON ORTHOTIC SERVICES
Entity Type:Organization
Organization Name:OREGON ORTHOTIC SERVICES
Other - Org Name:EVERGREEN PROSTHETICS AND ORTHOTICS
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:503-704-5408
Mailing Address - Street 1:8880 SW NIMBUS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7111
Mailing Address - Country:US
Mailing Address - Phone:877-971-7272
Mailing Address - Fax:
Practice Address - Street 1:8880 SW NIMBUS AVE STE A
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-7111
Practice Address - Country:US
Practice Address - Phone:877-971-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR27475Medicaid