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General NPI Number Information
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NPI Number | 1063742526
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Entity Type | Organization
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Legal Business Name | EVERGREEN HOME OF BERLIN, INC.
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Dates
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Enumeration Date | 01/06/2010
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Last Update Date | 01/06/2010
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Provider Practice Location Address
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Address Line | 508 E MARQUETTE ST
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City | BERLIN
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State | WI
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Zip | 54923-9404
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Country | US
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Telephone | 920-361-3231
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Fax | 920-361-3231
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Provider Business Mailing Address
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Address Line | 8429 IDYLLVIEW AVE
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City | SPARTA
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State | WI
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Zip | 54656-3617
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Country | US
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Telephone | 608-487-9067
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Fax | 608-487-9067
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Authorized Official
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Title or Position | PRESIDENT
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Name | LARENDA L ROSIN
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Credential |
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Telephone | 608-487-9067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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