MEDICARE: EVERGREEN DIAGNOSTICS

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	291U00000X	Clinical Medical Laboratory	23D1101213	MI

General Provider Information

NPI Number	:	1649503855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN DIAGNOSTICS

Provider Business Mailing Address
First Line	:	2025 S WASHINGTON AVE
Second Line	:	SUITE 210
City	:	LANSING
State	:	MI
Zip	:	48910-0828
Country	:	US
Telephone Number	:	517-371-1111
Fax Number	:	517-371-1121

Provider Business Practice Location Address
First Line	:	2025 S WASHINGTON AVE
Second Line	:	SUITE 210
City	:	LANSING
State	:	MI
Zip	:	48910-0828
Country	:	US
Telephone Number	:	517-371-1111
Fax Number	:	517-371-1121

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. THOMAS A FAULKNER
Credential	:
Telephone Number	:	517-371-1111

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	09/08/2009

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Directions to “EVERGREEN DIAGNOSTICS ” Practice Location

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