Healthcare Provider Details

I. General information

NPI: 1811795370
Provider Name (Legal Business Name): EVERGREEN TEAM HOLDINGS LLC - SUPPORTING BRIGHT FUTURES DBA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16745 BIG BEAR RD
LOWER LAKE CA
95457-9712
US

IV. Provider business mailing address

16745 BIG BEAR RD
LOWER LAKE CA
95457-9712
US

V. Phone/Fax

Practice location:
  • Phone: 707-266-9150
  • Fax: 707-922-0898
Mailing address:
  • Phone: 707-266-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: ANGELIQUE COLE
Title or Position: OWNER
Credential:
Phone: 707-206-5204