# CENTENNIAL MEDICAL GROUP EAST, LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** CENTENNIAL MEDICAL GROUP EAST, LLC
- **Other names:** Evergreen Family Medicine North
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1164124111
- **Legal business name:** CENTENNIAL MEDICAL GROUP EAST, LLC
- **Authorized official:** KIMBERLY TYREE (CHIEF OPERATING OFFICER)
- **Authorized official phone:** (541) 229-3332

## Contact information

- **Practice address:** 249 DAKOTA ST, SUTHERLIN, OR 97479-9908
- **Practice address phone:** (541) 677-7200
- **Practice address fax:** (541) 229-3309
- **Mailing address:** 2570 NW EDENBOWER BLVD STE 100, ROSEBURG, OR 97471-6214
- **Mailing address phone:** (541) 677-7200
- **Mailing address fax:** (541) 229-3309

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 03/21/2023
- **Last updated:** 03/21/2023