NPIMap

Organization Active NPI

Evergreen Prosthetics and Orthotics, LLC

  • Prosthetic/Orthotic Supplier
  • Meridian, ID
National Provider Identifier
1619508702
Registry record updated Nov 22, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Prosthetic/Orthotic SupplierTaxonomy code 335E00000X
Legal business name
EVERGREEN PROSTHETICS AND ORTHOTICS, LLC
Practice address
1500 E Heritage Park St Ste 100
Meridian, ID 83646-5884
Phone
(208) 884-1294
Fax
(208) 884-1293
NPI assigned
Jan 28, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 22, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy L O'Neill, CPO
Title
President
Phone
(503) 407-5408

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Prosthetic/Orthotic Supplier 335E00000X Primary

Addresses

Primary practice location

1500 E Heritage Park St Ste 100
Meridian, ID 83646-5884

Mailing address

911 Main St Ste 100
Oregon City, OR 97045-1853
Phone (503) 765-5081

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200327002429 ID DME Supplier - Orthotic PersonnelDME Supplier - Prosthetic Personnel 5890906432 Practice locations: Meridian, ID

Other NPIs with the same Medicare PAC ID 13

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Evergreen Prosthetics and Orthotics1500 E Heritage Park St, Meridian, ID 83646-5884(208) 884-1294 Contracture Treatment Devices: Dynamic Splint|Orthoses: Custom Fabricated|Orthoses: Prefabricated (Non-Custom Fabricated)|Orthoses: Off-The-Shelf|Limb Prostheses|Surgical Dressings|Diabetic Shoes and Inserts|Diabetic Shoes/Inserts - Custom Does not accept assignmentParticipating since Jan 1, 2023

National Provider Directory

National Provider Directory
Tax ID family
Oregon Orthotic Services15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

Organizations that report the same tax identification number in the National Provider Directory.

View all 14

Locations

1500 E Heritage Park St
Ste 100
Meridian, ID 83646
Phone (208) 884-1294

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1580169600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700611200000",
    "number": "1619508702",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "911 MAIN ST STE 100",
            "city": "OREGON CITY",
            "state": "OR",
            "postal_code": "970451853",
            "telephone_number": "503-765-5081",
            "fax_number": "971-316-1553"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 E HERITAGE PARK ST STE 100",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836465884",
            "telephone_number": "208-884-1294",
            "fax_number": "208-884-1293"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN PROSTHETICS AND ORTHOTICS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-28",
        "last_updated": "2023-11-22",
        "certification_date": "2023-11-22",
        "status": "A",
        "authorized_official_last_name": "O'NEILL",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "503-407-5408",
        "authorized_official_credential": "CPO"
    },
    "taxonomies": [
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Meridian, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.