MEDICARE: EVERGREEN URGENT CARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1487048963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN URGENT CARE INC

Provider Business Mailing Address
First Line	:	2110 MCKEE RD
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1427
Country	:	US
Telephone Number	:	408-258-5083
Fax Number	:	408-258-4347

Provider Business Practice Location Address
First Line	:	2365 QUIMBY ROAD
Second Line	:	SUITE 160
City	:	SAN JOSE
State	:	CA
Zip	:	95122-1337
Country	:	US
Telephone Number	:	408-258-5083
Fax Number	:	408-258-4347

Authorized Official
Title or Position	:	CEO/PHYSICIAN
Name	:	MR. TAM HOANG NGNYEN
Credential	:	D.O.
Telephone Number	:	408-258-5083

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	10/22/2015

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