Provider Demographics
NPI:1710731104
Name:EVERGREEN OPTOMETRY PLLC
Entity Type:Organization
Organization Name:EVERGREEN OPTOMETRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:716-831-2717
Mailing Address - Street 1:4845 TRANSIT RD APT B7
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4717
Mailing Address - Country:US
Mailing Address - Phone:716-831-2717
Mailing Address - Fax:
Practice Address - Street 1:17 LONG AVE STE 102
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-6200
Practice Address - Country:US
Practice Address - Phone:716-831-2717
Practice Address - Fax:716-831-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty