Healthcare Provider Details

I. General information

NPI: 1346300670
Provider Name (Legal Business Name): EVERGREEN PHYSICAL THERAPY SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S HUDSON AVE
PASADENA CA
91101-2606
US

IV. Provider business mailing address

PO BOX 50004
PASADENA CA
91115-0004
US

V. Phone/Fax

Practice location:
  • Phone: 626-683-8536
  • Fax: 626-683-8236
Mailing address:
  • Phone: 626-683-8536
  • Fax: 626-683-8236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT18149
License Number StateCA

VIII. Authorized Official

Name: TABITHA WANG
Title or Position: DIRECTOR OF RESOURCE MANAGEMENT
Credential:
Phone: 626-683-8536