| Evergreen Clinic Llc | |
|
1561 W 7000 S Ste 100 West Jordan UT 84084-3556 | |
| (801) 850-1958 | |
| (801) 747-6881 |
| Full Name | Evergreen Clinic Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 1561 W 7000 S Ste 100, West Jordan, Utah |
| Authorized Official Name and Position | Ignacio Nicolas Gonzalez (ADMINISTRATOR) |
| Authorized Official Contact | 8018501958 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Evergreen Clinic Llc Po Box 9193 Midvale UT 84047-9170 Ph: (801) 850-1958 | Evergreen Clinic Llc 1561 W 7000 S Ste 100 West Jordan UT 84084-3556 Ph: (801) 850-1958 |
| NPI Number | 1689210551 |
|---|---|
| Provider Enumeration Date | 11/25/2019 |
| Last Update Date | 01/13/2020 |
| Medicare PECOS PAC ID | 6507296407 |
|---|---|
| Medicare Enrollment ID | O20200416002115 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1689210551 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Jason Robert Vanshaar |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1497983076 PECOS PAC ID: 2961650734 Enrollment ID: I20170206001695 |
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