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

General Provider Information

NPI Number	:	1831262427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN PRESBYTERIAN MINISTRIES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 72360
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71172-2360
Country	:	US
Telephone Number	:	318-742-8440
Fax Number	:	318-752-5459

Provider Business Practice Location Address
First Line	:	4400 VIKING DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7413
Country	:	US
Telephone Number	:	318-742-8440
Fax Number	:	318-752-5459

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOHN R. TAYLOR
Credential	:
Telephone Number	:	318-742-8440

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	08/22/2020

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