Provider Demographics
NPI:1124366539
Name:EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Entity Type:Organization
Organization Name:EVERGREEN PRESBYTERIAN MINISTRIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT / CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MERLON
Authorized Official - Middle Name:K
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-949-5500
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:318-949-5500
Mailing Address - Fax:318-949-5555
Practice Address - Street 1:1340 HORRIDGE ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:LA
Practice Address - Zip Code:70668-4532
Practice Address - Country:US
Practice Address - Phone:318-949-5500
Practice Address - Fax:318-949-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6705251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1039161Medicaid