MEDICARE: EVERGREEN PRESBYTERIAN MINISTRIES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1679900476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PRESBYTERIAN MINISTRIES, INC.

Provider Business Mailing Address
First Line	:	2101 HIGHWAY 80
Second Line	:
City	:	HAUGHTON
State	:	LA
Zip	:	71037-9488
Country	:	US
Telephone Number	:	318-949-5500
Fax Number	:	318-949-5555

Provider Business Practice Location Address
First Line	:	2108 DIVISION STREET
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70663
Country	:	US
Telephone Number	:	318-949-5500
Fax Number	:	318-949-5555

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MERLON K CRAFT
Credential	:
Telephone Number	:	318-949-5500

Provider Enumeration Date	:	10/11/2013
Last Update Date	:	10/11/2013

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