1508984972 NPI number — EVERGREEN PRESBYTERIAN MINISTRIES OF EAST TN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508984972 NPI number — EVERGREEN PRESBYTERIAN MINISTRIES OF EAST TN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN PRESBYTERIAN MINISTRIES OF EAST TN
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:
1508984972
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:
1304 WILSON RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37912-5693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-689-4022
Provider Business Practice Location Address Fax Number:
865-689-4054
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: 00678 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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