Provider Demographics
NPI:1265954960
Name:EVERGREEN CLINIC, PLLC
Entity type:Organization
Organization Name:EVERGREEN CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:STILES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:443-622-9641
Mailing Address - Street 1:15670 HUNTON LN
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-1733
Mailing Address - Country:US
Mailing Address - Phone:443-622-9641
Mailing Address - Fax:703-753-9701
Practice Address - Street 1:14540 JOHN MARSHALL HWY STE 202
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-1693
Practice Address - Country:US
Practice Address - Phone:703-753-9700
Practice Address - Fax:703-753-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty