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General NPI Number Information
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NPI Number | 1649503855
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Entity Type | Organization
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Legal Business Name | EVERGREEN DIAGNOSTICS
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Dates
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Enumeration Date | 09/08/2009
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Last Update Date | 09/08/2009
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Provider Practice Location Address
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Address Line | 2025 S WASHINGTON AVE SUITE 210
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City | LANSING
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State | MI
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Zip | 48910-0828
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Country | US
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Telephone | 517-371-1111
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Fax | 517-371-1121
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Provider Business Mailing Address
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Address Line | 2025 S WASHINGTON AVE SUITE 210
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City | LANSING
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State | MI
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Zip | 48910-0828
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Country | US
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Telephone | 517-371-1111
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Fax | 517-371-1121
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. THOMAS A FAULKNER
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Credential |
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Telephone | 517-371-1111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 23D1101213
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License Number State | MI
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