MEDICARE: EVEREST HEALTHCARE INC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1528679586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVEREST HEALTHCARE INC

Provider Business Mailing Address
First Line	:	1815 BACK CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:	704-904-2862
Fax Number	:	704-716-7801

Provider Business Practice Location Address
First Line	:	224 EGLIN PKWY NE STE E
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-2877
Country	:	US
Telephone Number	:	850-215-4856
Fax Number	:	877-544-6997

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MR. SEMIR AJSIC
Credential	:
Telephone Number	:	704-904-2862

Provider Enumeration Date	:	08/13/2020
Last Update Date	:	08/13/2020

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