Healthcare Provider Details

I. General information

NPI: 1588790562
Provider Name (Legal Business Name): EVERGREEN FAMILY HEALTH PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 INDUSTRIAL AVE STE 130
WILLISTON VT
05495-4449
US

IV. Provider business mailing address

426 INDUSTRIAL AVE STE 130
WILLISTON VT
05495-4449
US

V. Phone/Fax

Practice location:
  • Phone: 802-878-1008
  • Fax: 802-872-2679
Mailing address:
  • Phone: 802-878-1008
  • Fax: 802-872-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATRINA PAYEA
Title or Position: CONTROLLER
Credential:
Phone: 802-878-1008