Basic Information
| Provider Information | |||||||||
| NPI: | 1548468762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVERGREEN BEHAVIORAL MANAGEMENT OF GEORGIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 425 | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284720425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106410600 | ||||||||
| FaxNumber: | 9106414178 | ||||||||
| Practice Location | |||||||||
| Address1: | 8657 HOSPITAL DR | ||||||||
| Address2: | SUITE 101 A | ||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301342298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709493118 | ||||||||
| FaxNumber: | 7709493228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | GINGER | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| 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 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.