Healthcare Provider Details

I. General information

NPI: 1316160534
Provider Name (Legal Business Name): EVERGREEN MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 E KIMBALLS LN STE 304
DRAPER UT
84020-5021
US

IV. Provider business mailing address

PO BOX 900280
SANDY UT
84090-0280
US

V. Phone/Fax

Practice location:
  • Phone: 801-676-7627
  • Fax: 801-676-7629
Mailing address:
  • Phone: 801-676-7627
  • Fax: 801-676-7629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARCI A MERRILL
Title or Position: BILLING MANAGER
Credential:
Phone: 801-676-7627