Organization
EVERGREEN CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
IGNACIO NICOLAS GONZALEZ (ADMINISTRATOR)
(801) 850-1958
Entity
Organization
Contact information
Practice address
1561 W 7000 S STE 100, WEST JORDAN, UT 84084-3556
(801) 850-1958
(801) 747-6881
Mailing address
PO BOX 9193, MIDVALE, UT 84047-9170
(801) 850-1958
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Enumeration date
11/25/2019
Last updated
01/13/2020
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