Healthcare Provider Details

I. General information

NPI: 1760159198
Provider Name (Legal Business Name): EVERGREEN SPINE AND PAIN CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3762 TIBBETTS ST
RIVERSIDE CA
92506-2605
US

IV. Provider business mailing address

3762 TIBBETTS ST
RIVERSIDE CA
92506-2605
US

V. Phone/Fax

Practice location:
  • Phone: 949-414-7246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. YI CAI ISAAC TONG
Title or Position: CEO
Credential: MD
Phone: 917-745-6888