Healthcare Provider Details

I. General information

NPI: 1396763298
Provider Name (Legal Business Name): EVERGREEN CLINI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2020
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 Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JERRY STEVENS
Title or Position: ADMINISTRATION
Credential:
Phone: 662-963-9154