Provider Demographics
NPI:1689860629
Name:EVERGREEN FAMILY MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:EVERGREEN FAMILY MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFNP/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JEANESSE
Authorized Official - Last Name:RUSHING
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-963-9154
Mailing Address - Street 1:4929 HIGHWAY 371 S
Mailing Address - Street 2:
Mailing Address - City:NETTLETON
Mailing Address - State:MS
Mailing Address - Zip Code:38858-6901
Mailing Address - Country:US
Mailing Address - Phone:662-963-9154
Mailing Address - Fax:662-963-9157
Practice Address - Street 1:4929 HIGHWAY 371 S
Practice Address - Street 2:
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38858-6901
Practice Address - Country:US
Practice Address - Phone:662-963-9154
Practice Address - Fax:662-963-9157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health