Evergreen Clinic LLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

EVERGREEN CLINIC LLC

Practice address

1561 W 7000 S Ste 100
West Jordan, UT 84084-3556

Phone

(801) 850-1958

Fax

(801) 747-6881

NPI assigned

Nov 25, 2019

Organization subpart

No

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

Authorized official

Name

Ignacio Nicolas Gonzalez

Title

Administrator

Phone

(801) 850-1958

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1574640000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1578873600000",
    "number": "1689210551",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 9193",
            "city": "MIDVALE",
            "state": "UT",
            "postal_code": "840479170",
            "telephone_number": "801-850-1958"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1561 W 7000 S STE 100",
            "city": "WEST JORDAN",
            "state": "UT",
            "postal_code": "840843556",
            "telephone_number": "801-850-1958",
            "fax_number": "801-747-6881"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-11-25",
        "last_updated": "2020-01-13",
        "certification_date": "2020-01-13",
        "status": "A",
        "authorized_official_last_name": "GONZALEZ",
        "authorized_official_first_name": "IGNACIO",
        "authorized_official_middle_name": "NICOLAS",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "801-850-1958"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Daniel Banta Ethington, LMT
• Andie Evans
• April Evans, PHARMD
• Lauren Evans, RN
• Maelyn Evans
• Eye Center of West Jordan, LLC
• Aleina Eyre, SUDC
• Cory J Fabrizio, DMD
• Fairbanks Family Dental
• Cassandra Fairclough, MSW, CSW

• Family Medicine Physician in West Jordan, UT
• Providers in West Jordan, UT by specialty
• Family Medicine Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.