Healthcare Provider Details

I. General information

NPI: 1689860629
Provider Name (Legal Business Name): EVERGREEN FAMILY MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4929 HIGHWAY 371 S
NETTLETON MS
38858-6901
US

IV. Provider business mailing address

4929 HIGHWAY 371 S
NETTLETON MS
38858-6901
US

V. Phone/Fax

Practice location:
  • Phone: 662-963-9154
  • Fax: 662-963-9157
Mailing address:
  • Phone: 662-963-9154
  • Fax: 662-963-9157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: MRS. CYNTHIA JEANESSE RUSHING
Title or Position: CFNP/OWNER
Credential: CFNP
Phone: 662-963-9154