# EVERGREEN CLINIC LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1689210551
- **Authorized official:** IGNACIO NICOLAS GONZALEZ (ADMINISTRATOR)
- **Authorized official phone:** (801) 850-1958

## Contact information

- **Practice address:** 1561 W 7000 S STE 100, WEST JORDAN, UT 84084-3556
- **Practice address phone:** (801) 850-1958
- **Practice address fax:** (801) 747-6881
- **Mailing address:** PO BOX 9193, MIDVALE, UT 84047-9170
- **Mailing address phone:** (801) 850-1958

## Taxonomy

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

## Other

- **Enumeration date:** 11/25/2019
- **Last updated:** 01/13/2020