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General NPI Number Information
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NPI Number | 1043409584
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Entity Type | Organization
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Legal Business Name | EVERGREEN ROAD FACILITY
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Dates
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Enumeration Date | 10/22/2007
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Last Update Date | 10/22/2007
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Provider Practice Location Address
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Address Line | 827 EVERGREEN RD
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City | ROCKY MOUNT
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State | NC
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Zip | 27803-2426
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Country | US
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Telephone | 252-446-8675
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Fax |
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Provider Business Mailing Address
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Address Line | 7227 LEE DEFOREST DR
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City | COLUMBIA
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State | MD
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Zip | 21046-3236
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CONTROLLER
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Name | MR. DUANE BRICKHOUSE
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Credential |
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Telephone | 410-910-1489
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 064-079
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License Number State | NC
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