Provider Demographics
NPI:1689210551
Name:EVERGREEN CLINIC LLC
Entity Type:Organization
Organization Name:EVERGREEN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IGNACIO
Authorized Official - Middle Name:NICOLAS
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-850-1958
Mailing Address - Street 1:PO BOX 9193
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-9170
Mailing Address - Country:US
Mailing Address - Phone:801-850-1958
Mailing Address - Fax:
Practice Address - Street 1:1561 W 7000 S STE 100
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3556
Practice Address - Country:US
Practice Address - Phone:801-850-1958
Practice Address - Fax:801-747-6881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty