Provider Demographics
NPI:1942710256
Name:EVERGREEN TESTOSTERONE CLINIC & PRIMARY CARE
Entity Type:Organization
Organization Name:EVERGREEN TESTOSTERONE CLINIC & PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAMWIRI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:214-870-0885
Mailing Address - Street 1:619 MATLOCK CENTRE CIR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2535
Mailing Address - Country:US
Mailing Address - Phone:214-870-0885
Mailing Address - Fax:
Practice Address - Street 1:619 MATLOCK CENTRE CIR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2535
Practice Address - Country:US
Practice Address - Phone:214-870-0885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care