Provider Demographics
NPI:1912613308
Name:EVERGREENE MOBILE PHLEBOTOMY
Entity Type:Organization
Organization Name:EVERGREENE MOBILE PHLEBOTOMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATIMA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-587-2323
Mailing Address - Street 1:116 LAFAYETTE PL
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3328
Mailing Address - Country:US
Mailing Address - Phone:551-587-2323
Mailing Address - Fax:
Practice Address - Street 1:116 LAFAYETTE PL
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3328
Practice Address - Country:US
Practice Address - Phone:551-587-2323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty