Basic Information
| Provider Information | |||||||||
| NPI: | 1396984373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN BEHAVIORAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 425 | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284722220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106410600 | ||||||||
| FaxNumber: | 9106410606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1409 PINCKNEY STREET | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284722220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106410600 | ||||||||
| FaxNumber: | 9106410606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2009 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | GINGER | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9106410600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVERGREEN BEHAVIORAL MANAGEMENT, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 8702201 | 05 | NC | MEDICAID | 3408980 | 05 | NC | MEDICAID |