Provider Demographics
NPI:1073719845
Name:EVERGREEN PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:EVERGREEN PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:VAN DRIL
Authorized Official - Last Name:SWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:269-381-0737
Mailing Address - Street 1:611 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1919
Mailing Address - Country:US
Mailing Address - Phone:269-381-0737
Mailing Address - Fax:269-381-5120
Practice Address - Street 1:611 HOWARD ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1919
Practice Address - Country:US
Practice Address - Phone:269-381-0737
Practice Address - Fax:269-381-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty