Healthcare Provider Details

I. General information

NPI: 1881049211
Provider Name (Legal Business Name): EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 EAST PECAN ST.
PONCHATOULA LA
70454
US

IV. Provider business mailing address

2101 HIGHWAY 80
HAUGHTON LA
71037-9488
US

V. Phone/Fax

Practice location:
  • Phone: 985-386-2360
  • Fax: 985-386-9380
Mailing address:
  • Phone: 318-949-5500
  • Fax: 318-949-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MERLON KENT CRAFT
Title or Position: EXECUTIVE VICE PRESIDENT / CFO
Credential:
Phone: 318-949-5515