Provider Demographics
NPI:1952767485
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:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
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:971-316-1553
Practice Address - Street 1:149 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4168
Practice Address - Country:US
Practice Address - Phone:503-208-3699
Practice Address - Fax:503-208-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies