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General NPI Number Information
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NPI Number | 1992144240
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Entity Type | Organization
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Legal Business Name | EVERGREEN MEDICAL COSMETIC LASER CENTER
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Dates
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Enumeration Date | 06/20/2013
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Last Update Date | 06/20/2013
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Provider Practice Location Address
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Address Line | 104 1ST AVE EAST
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City | ONEONTA
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State | AL
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Zip | 35121
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Country | US
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Telephone | 205-834-2672
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Fax |
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Provider Business Mailing Address
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Address Line | 1638 CROSSGATE DR
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City | BIRMINGHAM
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State | AL
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Zip | 35216
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Country | US
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Telephone | 205-834-2672
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Fax |
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Authorized Official
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Title or Position | MD
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Name | DR. JIAN HUAI FONG
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Credential | MD
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Telephone | 205-834-2672
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 27530
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License Number State | AL
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