| Organization Name: | EVERGREEN ENDOSCOPY CENTER, LLC |
| NPI Number: | 1093974602 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KATHY ANN MAZEROLLE (NURSE ADMINISTRATOR) |
| Mailing Address: | 2400 Tamarack Avenue Suite 100 South Windsor |
| State: | CT US |
| Postal Code: | 06074 |
| Phone Number: | 8606447336 |
| Fax Number: | |
| NPI Enumeration Date: | 06/09/2008 |
| NPI Last Update Date: | 02/11/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QE0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Endoscopy |
| Taxonomy Definition: | |