MEDICARE: EVERGREEN NURSING HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	12509	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285693762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN NURSING HOME, LLC

Provider Business Mailing Address
First Line	:	501 WHETSTONE ST
Second Line	:
City	:	MONROEVILLE
State	:	AL
Zip	:	36460-2615
Country	:	US
Telephone Number	:	251-743-3609
Fax Number	:	251-575-5618

Provider Business Practice Location Address
First Line	:	100 SANDERS DR
Second Line	:
City	:	EVERGREEN
State	:	AL
Zip	:	36401-3306
Country	:	US
Telephone Number	:	251-578-3783
Fax Number	:	251-578-3786

Authorized Official
Title or Position	:	CFO
Name	:	NOEL DUNNAM
Credential	:
Telephone Number	:	251-743-7137

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	03/06/2024

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