Provider Demographics
NPI:1346208659
Name:EVERGREEN SPORT & SPINE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:EVERGREEN SPORT & SPINE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-670-4802
Mailing Address - Street 1:26719 PLEASANT PARK RD UNIT 220
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-7756
Mailing Address - Country:US
Mailing Address - Phone:303-838-1970
Mailing Address - Fax:303-838-2433
Practice Address - Street 1:26719 PLEASANT PARK RD UNIT 220
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-7756
Practice Address - Country:US
Practice Address - Phone:303-838-1970
Practice Address - Fax:303-838-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCN3003Medicare PIN