Healthcare Provider Details

I. General information

NPI: 1437067030
Provider Name (Legal Business Name): EVERGREEN EQUIPMENT SUPPLIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12714 NETTLECREEK PL
WOODBRIDGE VA
22192-8003
US

IV. Provider business mailing address

12714 NETTLECREEK PL
WOODBRIDGE VA
22192-8003
US

V. Phone/Fax

Practice location:
  • Phone: 737-305-6291
  • Fax: 737-305-8734
Mailing address:
  • Phone: 737-305-6291
  • Fax: 737-305-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL

VIII. Authorized Official

Name: BAREERA SADIQ
Title or Position: CEO
Credential:
Phone: 737-305-6291