Healthcare Provider Details

I. General information

NPI: 1881677581
Provider Name (Legal Business Name): EVERGREEN MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 SOUTH MAIN ST
EVERGREEN AL
36401
US

IV. Provider business mailing address

308 SOUTH MAIN ST
EVERGREEN AL
36401
US

V. Phone/Fax

Practice location:
  • Phone: 251-578-6800
  • Fax: 251-578-0252
Mailing address:
  • Phone: 251-578-6800
  • Fax: 251-578-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number10419
License Number StateAL

VIII. Authorized Official

Name: MRS. SHARON JONES
Title or Position: CFO
Credential:
Phone: 251-578-2480