Provider Demographics
NPI:1093365215
Name:EVERGREEN LIFE SERVICES OF FLORIDA, INC.
Entity Type:Organization
Organization Name:EVERGREEN LIFE SERVICES OF FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MERLON
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-949-5515
Mailing Address - Street 1:2101 HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-9488
Mailing Address - Country:US
Mailing Address - Phone:318-949-5515
Mailing Address - Fax:318-949-5555
Practice Address - Street 1:2101 STARKEY RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-5340
Practice Address - Country:US
Practice Address - Phone:727-748-6203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services