Provider Demographics
NPI:1255723391
Name:EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
Entity type:Organization
Organization Name:EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-407-5408
Mailing Address - Street 1:911 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1853
Mailing Address - Country:US
Mailing Address - Phone:503-765-5081
Mailing Address - Fax:971-315-1553
Practice Address - Street 1:1424 N MCDONALD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-6017
Practice Address - Country:US
Practice Address - Phone:509-926-1403
Practice Address - Fax:509-926-1404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN PROSTHETICS & ORTHOTICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-26
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5463340005Medicare PIN