Provider Demographics
NPI:1700850450
Name:TRIPPLE O EVERGREEN
Entity Type:Organization
Organization Name:TRIPPLE O EVERGREEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:OGBAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:OGBU
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:310-965-9039
Mailing Address - Street 1:17420 AVALON BLVD
Mailing Address - Street 2:207
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1564
Mailing Address - Country:US
Mailing Address - Phone:310-965-9039
Mailing Address - Fax:310-965-9099
Practice Address - Street 1:17420 AVALON BLVD
Practice Address - Street 2:207
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1564
Practice Address - Country:US
Practice Address - Phone:310-965-9039
Practice Address - Fax:310-965-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4306560001Medicare ID - Type UnspecifiedHMDR