Provider Demographics
NPI:1710073176
Name:EVERGREEN AESTHETIC INSTITUTE LLC
Entity Type:Organization
Organization Name:EVERGREEN AESTHETIC INSTITUTE LLC
Other - Org Name:EAI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-342-7090
Mailing Address - Street 1:1104 W EVERGREEN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-1710
Mailing Address - Country:US
Mailing Address - Phone:217-342-7090
Mailing Address - Fax:217-342-7094
Practice Address - Street 1:1104 W EVERGREEN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1710
Practice Address - Country:US
Practice Address - Phone:217-342-7090
Practice Address - Fax:217-342-7094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2198261QA0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility