Provider Demographics
NPI: | 1952767485 |
---|---|
Name: | EVERGREEN PROSTHETICS AND ORTHOTICS, LLC |
Entity Type: | Organization |
Organization Name: | EVERGREEN PROSTHETICS AND ORTHOTICS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | TIMOTHY |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | O'NEILL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | CPO |
Authorized Official - Phone: | 503-407-5408 |
Mailing Address - Street 1: | 911 MAIN ST STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | OREGON CITY |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97045-1853 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-765-5081 |
Mailing Address - Fax: | 971-316-1553 |
Practice Address - Street 1: | 149 NE 102ND AVE |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97220-4168 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-208-3699 |
Practice Address - Fax: | 503-208-2210 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-01-13 |
Last Update Date: | 2023-11-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 335E00000X | Suppliers | Prosthetic/Orthotic Supplier | |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |