Provider Demographics
NPI:1689615874
Name:EVERGREEN, INC
Entity Type:Organization
Organization Name:EVERGREEN, INC
Other - Org Name:EVERGREEN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:406-756-7225
Mailing Address - Street 1:2181 HWY 2, EAST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-756-7225
Mailing Address - Fax:
Practice Address - Street 1:2181 HWY 2, EAST
Practice Address - Street 2:SUITE 9
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-756-7225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT84802Medicare PIN