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1780206250 NPI number — EVERGREEN ASSISTED LIVING COMMUNITY LLC

NPI Number: 1780206250
Health Care Provider/Practitioner: EVERGREEN ASSISTED LIVING COMMUNITY LLC

Information about “1780206250” NPI (EVERGREEN ASSISTED LIVING COMMUNITY LLC) exists in 1780206250 in HTML format HTML  |  1780206250 in plain Text format TXT  |  1780206250 in PDF (Portable Document Format) PDF  |  1780206250 in an XML format XML  formats.

NPI Number : 1780206250 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1780206250",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "EVERGREEN ASSISTED LIVING COMMUNITY LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "4222 MOOMAW AVE NW",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "ROANOKE",
    "MailingAddressStateName": "VA",
    "MailingAddressPostalCode": "24017-4314",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "540-613-0757",
    "MailingAddressFaxNumber": "540-491-9319",
    "FirstLinePracticeLocationAddress": "4222 MOOMAW AVE NW",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "ROANOKE",
    "PracticeLocationAddressStateName": "VA",
    "PracticeLocationAddressPostalCode": "24017-4314",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "540-613-0757",
    "PracticeLocationAddressFaxNumber": "540-491-9319",
    "EnumerationDate": "05/07/2020",
    "LastUpdateDate": "05/07/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "ODUPELU",
    "AuthorizedOfficialFirstName": "PATIENCE",
    "AuthorizedOfficialMiddleName": "OGWA",
    "AuthorizedOfficialTitle": "OWNER/ PROGRAM DIRECTOR",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": "540-613-0757",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "320900000X",
        "TaxonomyName": "Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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