Healthcare Provider Details

I. General information

NPI: 1831218767
Provider Name (Legal Business Name): EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL VALLEY RD STE 104
GRESHAM OR
97080-1495
US

IV. Provider business mailing address

911 MAIN ST STE 100
OREGON CITY OR
97045-1853
US

V. Phone/Fax

Practice location:
  • Phone: 503-660-3180
  • Fax: 503-660-3180
Mailing address:
  • Phone: 503-765-5081
  • Fax: 971-316-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number681350
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number681350
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY L O'NEILL
Title or Position: OWNER
Credential: CPO
Phone: 503-407-5408