Healthcare Provider Details

I. General information

NPI: 1306116637
Provider Name (Legal Business Name): EVERGREEN GERIATRIC CARE MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 STOVALL ST
AUGUSTA GA
30904-6215
US

IV. Provider business mailing address

1521 STOVALL ST
AUGUSTA GA
30904-6215
US

V. Phone/Fax

Practice location:
  • Phone: 706-288-5428
  • Fax:
Mailing address:
  • Phone: 706-288-5428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberCSW004126
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberCSW004126
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberCSW004126
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberCSW004126
License Number StateGA

VIII. Authorized Official

Name: MS. EVE WILLIAMS PEARSON
Title or Position: OWNER/THERAPIST
Credential: LCSW, C-ASWCM
Phone: 706-288-5428