Healthcare Provider Details

I. General information

NPI: 1124206867
Provider Name (Legal Business Name): EVERGREEN HEARING CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 NE BAKER ST
MCMINNVILLE OR
97128-4932
US

IV. Provider business mailing address

1024 NE BAKER ST
MCMINNVILLE OR
97128-4932
US

V. Phone/Fax

Practice location:
  • Phone: 503-472-8850
  • Fax:
Mailing address:
  • Phone: 503-472-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P 209627
License Number StateOR

VIII. Authorized Official

Name: MR. CHRISTOPHER GUSTAFSON
Title or Position: OWNER
Credential:
Phone: 503-472-8850