=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851721344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN PINES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2013
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 343 E CUMBERLAND ST
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54923-1206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-290-3305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 506
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54656-0506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-229-3664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KERI M HAYWOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-229-3664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 14846
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------