MEDICARE: EVERGREEN EMPOWERMENT GROUP 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1679998066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN EMPOWERMENT GROUP INC

Provider Business Mailing Address
First Line	:	35104 EUCLID AVE STE 314
Second Line	:
City	:	WILLOUGHBY
State	:	OH
Zip	:	44094-4566
Country	:	US
Telephone Number	:	216-703-0067
Fax Number	:

Provider Business Practice Location Address
First Line	:	35104 EUCLID AVE STE 314
Second Line	:
City	:	WILLOUGHBY
State	:	OH
Zip	:	44094-4566
Country	:	US
Telephone Number	:	216-703-0067
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KARMEN COLE
Credential	:
Telephone Number	:	216-703-0067

Provider Enumeration Date	:	02/22/2014
Last Update Date	:	11/13/2019

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