=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023503497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2018
-----------------------------------------------------
Last Update Date | 10/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1818 S 10TH AVE STE 240
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-4880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-608-6014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 911 MAIN ST STE 100
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-1853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-765-5081
-----------------------------------------------------
Fax | 971-316-1553
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIMOTHY L O'NEILL
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 503-407-5408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------