Provider Demographics
NPI:1710365416
Name:EVERSIDE HEALTH, LLC
Entity Type:Organization
Organization Name:EVERSIDE HEALTH, LLC
Other - Org Name:EVERSIDE HEALTH - PUEBLO FORTINO BLVD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RISK MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-936-5546
Mailing Address - Street 1:4651 CHARLOTTE PARK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1916
Mailing Address - Country:US
Mailing Address - Phone:866-808-6005
Mailing Address - Fax:
Practice Address - Street 1:1300 FORTINO BLVD STE C
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2078
Practice Address - Country:US
Practice Address - Phone:719-404-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVITA DPC HOLDING, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-13
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty