=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821897992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 E 10TH ST
-----------------------------------------------------
City | BAXTER SPRINGS
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66713-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-856-2756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 92
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64858-0092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-850-3063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LARRY ROBERT HIGGINBOTHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-850-3063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------