Basic Information
| Provider Information | |||||||||
| NPI: | 1588816789 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN BEHAVIORAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRENTON HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 425 | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284720425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106410600 | ||||||||
| FaxNumber: | 9106410606 | ||||||||
| Practice Location | |||||||||
| Address1: | 5794 OLD HIGHWAY 74 | ||||||||
| Address2: | |||||||||
| City: | CHADBOURN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284316779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106543591 | ||||||||
| FaxNumber: | 9106543591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | GINGER | ||||||||
| AuthorizedOfficialMiddleName: | GAYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9106410600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EVERGREEN BEHAVIORAL MANAGEMENT, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | MHL024074 | NC | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 6603239 | 05 | NC | MEDICAID |