1467570051 NPI number — EVERGREEN OK DAILY LIVING SUPPORT

Table of content: (NPI 1467570051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467570051 NPI number — EVERGREEN OK DAILY LIVING SUPPORT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN OK DAILY LIVING SUPPORT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467570051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 HIGHWAY 80
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAUGHTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71037-9488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-742-8440
Provider Business Mailing Address Fax Number:
318-752-5448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7725 W BRITTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73132-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-720-1192
Provider Business Practice Location Address Fax Number:
405-720-1193
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
318-742-8440

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100645750H-G820 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com