Healthcare Provider Details

I. General information

NPI: 1316143175
Provider Name (Legal Business Name): EVERGREEN DICKINSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2143 6TH AVE W
DICKINSON ND
58601-2700
US

IV. Provider business mailing address

2143 6TH AVE W
DICKINSON ND
58601-2700
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-6606
  • Fax:
Mailing address:
  • Phone: 701-483-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number8054A
License Number StateND

VIII. Authorized Official

Name: MRS. VICKIE COFER
Title or Position: ASST. DIRECTOR
Credential:
Phone: 701-483-6606