Provider Demographics
NPI:1649503855
Name:EVERGREEN DIAGNOSTICS
Entity type:Organization
Organization Name:EVERGREEN DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-371-1111
Mailing Address - Street 1:2025 S WASHINGTON AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-0828
Mailing Address - Country:US
Mailing Address - Phone:517-371-1111
Mailing Address - Fax:517-371-1121
Practice Address - Street 1:2025 S WASHINGTON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-0828
Practice Address - Country:US
Practice Address - Phone:517-371-1111
Practice Address - Fax:517-371-1121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D1101213291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory