Provider Demographics
NPI:1801501523
Name:EVERGREEN RECOVERY CLINICAL LABORATORY
Entity type:Organization
Organization Name:EVERGREEN RECOVERY CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEIM
Authorized Official - Suffix:
Authorized Official - Credentials:CPRS
Authorized Official - Phone:651-252-6078
Mailing Address - Street 1:1400 ENERGY PARK DR STE 21
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5248
Mailing Address - Country:US
Mailing Address - Phone:651-252-6078
Mailing Address - Fax:651-252-6071
Practice Address - Street 1:1400 ENERGY PARK DR STE 21
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5248
Practice Address - Country:US
Practice Address - Phone:651-252-6078
Practice Address - Fax:651-252-6071
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN RECOVERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory