Healthcare Provider Details

I. General information

NPI: 1841039583
Provider Name (Legal Business Name): EVERGREEN SENIOR HEALTHCARE OF MAINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ANTHONY AVE
AUGUSTA ME
04330-8089
US

IV. Provider business mailing address

108 ANTHONY AVE
AUGUSTA ME
04330-8089
US

V. Phone/Fax

Practice location:
  • Phone: 207-872-8992
  • Fax: 207-430-3565
Mailing address:
  • Phone: 207-872-8992
  • Fax: 207-430-3565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LEANN SEBREY
Title or Position: CHIEF OPERATING OFFICER
Credential: RN
Phone: 207-542-0770