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General NPI Number Information
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NPI Number | 1063184141
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Entity Type | Organization
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Legal Business Name | EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
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Dates
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Enumeration Date | 09/28/2021
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Last Update Date | 11/01/2023
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Provider Practice Location Address
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Address Line | 2121 NE 139TH ST BLDG 1 STE 225
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City | VANCOUVER
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State | WA
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Zip | 98686-2316
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Country | US
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Telephone | 503-765-5081
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Fax |
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Provider Business Mailing Address
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Address Line | 911 MAIN ST STE 100
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City | OREGON CITY
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State | OR
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Zip | 97045-1853
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Country | US
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Telephone | 503-765-5081
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Fax | 971-316-1553
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Authorized Official
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Title or Position | PRESIDENT
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Name | TIM O'NEILL
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Credential | CPO
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Telephone | 503-407-5408
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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