Provider Demographics
NPI:1528326782
Name:EVERGREEN IPA INC.
Entity type:Organization
Organization Name:EVERGREEN IPA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:DONADIO
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:CPCO
Authorized Official - Phone:626-943-7465
Mailing Address - Street 1:1032 S GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4762
Mailing Address - Country:US
Mailing Address - Phone:626-943-7465
Mailing Address - Fax:626-458-8051
Practice Address - Street 1:1032 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-4762
Practice Address - Country:US
Practice Address - Phone:626-943-7465
Practice Address - Fax:626-458-8051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34137302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAS8800220OtherDEA
CAA27387Medicare UPIN