Healthcare Provider Details

I. General information

NPI: 1255452017
Provider Name (Legal Business Name): EVERGREEN LIVING #4
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 FAMILY RIDGE ROAD
LEICESTER NC
28748
US

IV. Provider business mailing address

PO BOX 2077
LEICESTER NC
28748-2077
US

V. Phone/Fax

Practice location:
  • Phone: 828-779-5588
  • Fax:
Mailing address:
  • Phone: 828-779-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-011-196
License Number StateNC

VIII. Authorized Official

Name: YOUNG S LEE
Title or Position: OWNER
Credential:
Phone: 828-779-5588