Healthcare Provider Details

I. General information

NPI: 1366465403
Provider Name (Legal Business Name): THE EVERGREENS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4007 W WENDOVER AVE
GREENSBORO NC
27407-1904
US

IV. Provider business mailing address

4007 W WENDOVER AVE
GREENSBORO NC
27407-1904
US

V. Phone/Fax

Practice location:
  • Phone: 336-292-8620
  • Fax: 336-854-7122
Mailing address:
  • Phone: 336-292-8620
  • Fax: 336-854-7122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberNH0073
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0073
License Number StateNC

VIII. Authorized Official

Name: MS. MARILYN GARDNER
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 336-292-8620