Basic Information
| Provider Information | |||||||||
| NPI: | 1043459647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN BEHAVIORAL MANAGEMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 425 | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284720425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106405512 | ||||||||
| FaxNumber: | 9106410606 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 G & H WINTERGREEN DR | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107389420 | ||||||||
| FaxNumber: | 9106719414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2009 | ||||||||
| LastUpdateDate: | 03/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | GINGER | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9106405512 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8300536 | 05 | NC | MEDICAID |