Provider Demographics
NPI:1043409584
Name:EVERGREEN ROAD FACILITY
Entity Type:Organization
Organization Name:EVERGREEN ROAD FACILITY
Other - Org Name:CARE FOCUS, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRICKHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-910-1489
Mailing Address - Street 1:7227 LEE DEFOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-3236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:827 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-2426
Practice Address - Country:US
Practice Address - Phone:252-446-8675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC064-079320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC064-079OtherLICENSE
NC7804569Medicaid