Healthcare Provider Details

I. General information

NPI: 1710073176
Provider Name (Legal Business Name): EVERGREEN AESTHETIC INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 W EVERGREEN AVE SUITE B
EFFINGHAM IL
62401-1710
US

IV. Provider business mailing address

1104 W EVERGREEN AVE SUITE B
EFFINGHAM IL
62401-1710
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-7090
  • Fax: 217-342-7094
Mailing address:
  • Phone: 217-342-7090
  • Fax: 217-342-7094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number2198
License Number StateIL

VIII. Authorized Official

Name: DR. THEODORE FIFER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 217-342-7090