1487048963 NPI number — EVERGREEN URGENT CARE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487048963 NPI number — EVERGREEN URGENT CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN URGENT CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487048963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2365 QUIMBY ROAD
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95122-1337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-258-5083
Provider Business Practice Location Address Fax Number:
408-258-4347
Provider Enumeration Date:
03/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NGNYEN
Authorized Official First Name:
TAM
Authorized Official Middle Name:
HOANG
Authorized Official Title or Position:
CEO/PHYSICIAN
Authorized Official Telephone Number:
408-258-5083

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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