1366465403 NPI number — THE EVERGREENS, INC.

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 1366465403 NPI number — THE EVERGREENS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EVERGREENS, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1366465403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4007 W WENDOVER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27407-1904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-292-8620
Provider Business Mailing Address Fax Number:
336-854-7122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4007 W WENDOVER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27407-1904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-292-8620
Provider Business Practice Location Address Fax Number:
336-854-7122
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
336-292-8620

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  NH0073 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: NH0073 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3405016 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 40251 . This is a "PARTNERS INS PROVIDER NO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 00829 . This is a "BCBS OF NC PROVIDER NO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3406162 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com