Provider Demographics
NPI:1700447968
Name:EVERGREEN CIRCUITS LLC
Entity Type:Organization
Organization Name:EVERGREEN CIRCUITS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBERR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-382-8412
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-1304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14023 284TH CIR NE
Practice Address - Street 2:
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019-8176
Practice Address - Country:US
Practice Address - Phone:425-382-8412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies