NPIMap

Organization Active NPI

Evergreen Prosthetics and Orthotics, LLC

  • Prosthetic/Orthotic Supplier
  • Portland, OR
National Provider Identifier
1922299429
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
11782 SW Barnes Rd
Ste 160E
Portland, OR 97225-5914
Phone
(503) 641-2020
Fax
(503) 574-3274
NPI assigned
Aug 8, 2007
Last updated
Nov 22, 2023By the provider in NPPES
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, CPONPI 1700400249
Title
Owner
Phone
(503) 407-5408

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Prosthetic/Orthotic Supplier 335E00000X Primary

Addresses

Primary practice location

11782 SW Barnes Rd
Ste 160E
Portland, OR 97225-5914

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
274750MedicaidOR

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100930037180 OR DME Supplier - Prosthetic PersonnelDME Supplier - Orthotic Personnel 5890906432 Practice locations: Portland, OR

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 & Orthotics11782 SW Barnes Rd, Portland, OR 97225-5914(503) 641-2020 Orthoses: Custom Fabricated|Orthoses: Prefabricated (Non-Custom Fabricated)|Orthoses: Off-The-Shelf|Limb Prostheses|Diabetic Shoes and Inserts|Diabetic Shoes/Inserts - Custom|Lymphedema Compression Treatment Items Does not accept assignmentParticipating since Jan 1, 2023

National Provider Directory

National Provider Directory
Tax ID family
Evergreen Prosthetics and Orthotics LLC15 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

11782 SW Barnes Rd
Ste 160E
Portland, OR 97225
Phone (503) 641-2020

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1186531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700611200000",
    "number": "1922299429",
    "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": "11782 SW BARNES RD",
            "address_2": "STE 160E",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972255914",
            "telephone_number": "503-641-2020",
            "fax_number": "503-574-3274"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN PROSTHETICS AND ORTHOTICS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-08-08",
        "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": "OWNER",
        "authorized_official_telephone_number": "503-407-5408",
        "authorized_official_credential": "CPO"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "274750",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

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.