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EVERGREEN PHYSICAL MEDICINE LLC

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Company Details

Name: EVERGREEN PHYSICAL MEDICINE LLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 24 Jan 2018 (7 years ago)
Financial Date End: 31 Jan 2020
Date dissolved: 08 Apr 2020
Entity Number: 590200
Place of Formation: IDAHO
File Number: 590200
ZIP code: 83646
County: Ada County
Principal Address: 1710 W CHERRY LN MERIDIAN, ID 83646
Mailing Address: 1710 W CHERRY LN MERIDIAN, ID 83642-1340

Agent

Name Role Address
MATTHEW HALES Agent 1710 W CHERRY LN, MERIDIAN, ID 83642

National Provider Identifier

NPI Number:
1538668421

Authorized Person:

Name:
SUMMER DANCE
Role:
EXECUTIVE DIRECTOR
Phone:

Taxonomy:

Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
Yes

Contacts:

Filing

Filing Name Filing Number Filing date
Dissolution/Revocation - Administrative 0003838681 2020-04-08
Change of Registered Office/Agent/Both (by Entity) 0003420445 2019-02-01
Annual Report 0003417909 2019-01-30
Initial Filing 0000590200 2018-01-24

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Date of last update: 04 Jul 2025

Sources: Idaho Secretary of State