Healthcare Provider Details

I. General information

NPI: 1952653024
Provider Name (Legal Business Name): EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 PENNY DR
VINTON LA
70668-4905
US

IV. Provider business mailing address

2101 HIGHWAY 80
HAUGHTON LA
71037-9488
US

V. Phone/Fax

Practice location:
  • Phone: 318-949-5500
  • Fax: 318-949-5555
Mailing address:
  • Phone: 318-949-5500
  • Fax: 318-949-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number220378161
License Number StateLA

VIII. Authorized Official

Name: MR. MERLON K CRAFT
Title or Position: CFO
Credential:
Phone: 318-949-5500