Provider Demographics
NPI:1700021151
Name:EVERGREEN PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:EVERGREEN PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:208-736-0887
Mailing Address - Street 1:PO BOX 1886
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-1886
Mailing Address - Country:US
Mailing Address - Phone:208-736-0887
Mailing Address - Fax:208-736-0890
Practice Address - Street 1:491 CASWELL AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3743
Practice Address - Country:US
Practice Address - Phone:208-736-0887
Practice Address - Fax:208-736-0890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty