=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043356009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN PRESBYTERIAN MINISTRIES OF TEXAS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 12/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 WOOD ST
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-4472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-794-0517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 HIGHWAY 80
-----------------------------------------------------
City | HAUGHTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71037-9488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-949-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SUSAN M BUCHHOLTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-949-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 118062
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------