Provider Demographics
NPI:1679312987
Name:EVERGREEN GABLES PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:EVERGREEN GABLES PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONG HYOUK
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:347-242-0032
Mailing Address - Street 1:87 MANORHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1521
Mailing Address - Country:US
Mailing Address - Phone:347-242-0032
Mailing Address - Fax:
Practice Address - Street 1:6424 11TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5639
Practice Address - Country:US
Practice Address - Phone:718-333-5369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty