=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235580820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN SUPPORTED LIVING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2016
-----------------------------------------------------
Last Update Date | 06/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 E MAIN ST STE 102
-----------------------------------------------------
City | WHITEHALL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43213-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-205-9982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5150 E MAIN ST STE 102
-----------------------------------------------------
City | WHITEHALL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43213-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-205-9982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ANTA MOORE
-----------------------------------------------------
Credential | DBA, MSN, CNP
-----------------------------------------------------
Telephone | 614-205-9982
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------