Provider Demographics
NPI:1891780151
Name:EVERGREEN PHYSICAL THERAPY, P.S.
Entity Type:Organization
Organization Name:EVERGREEN PHYSICAL THERAPY, P.S.
Other - Org Name:JAY A. SMITH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-428-6677
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-1789
Mailing Address - Country:US
Mailing Address - Phone:360-428-6677
Mailing Address - Fax:360-428-7635
Practice Address - Street 1:2226 MARKET ST STE C
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5451
Practice Address - Country:US
Practice Address - Phone:360-428-6677
Practice Address - Fax:360-428-7635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2019-01-24
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
WA703843Medicaid
WAGAB08622Medicare PIN