Provider Demographics
NPI:1346300670
Name:EVERGREEN PHYSICAL THERAPY SPECIALISTS, INC
Entity Type:Organization
Organization Name:EVERGREEN PHYSICAL THERAPY SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF RESOURCE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-683-8536
Mailing Address - Street 1:PO BOX 50004
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91115-0004
Mailing Address - Country:US
Mailing Address - Phone:626-683-8536
Mailing Address - Fax:626-683-8236
Practice Address - Street 1:111 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2606
Practice Address - Country:US
Practice Address - Phone:626-683-8536
Practice Address - Fax:626-683-8236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18149261QP2000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18442Medicare ID - Type Unspecified