MEDICARE: EVERGREEN PRESBYTERIAN MINISTRIES, 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	315P00000X	Intellectual Disabilities Intermediate Care Facility	643	LA

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	:	1760537625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PRESBYTERIAN MINISTRIES, INC.

Provider Business Mailing Address
First Line	:	2101 HIGHWAY 80
Second Line	:
City	:	HAUGHTON
State	:	LA
Zip	:	71037-9488
Country	:	US
Telephone Number	:	318-949-5500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 WILLOWICK ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-2018
Country	:	US
Telephone Number	:	337-474-6837
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN R TAYLOR
Credential	:
Telephone Number	:	318-949-5500

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	06/13/2008

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