Provider Demographics
NPI:1154653897
Name:EVERGREEN COMMUNITY SUPPORTS, LLC
Entity Type:Organization
Organization Name:EVERGREEN COMMUNITY SUPPORTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-644-2584
Mailing Address - Street 1:104 OLD BOTTOM ROAD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391
Mailing Address - Country:US
Mailing Address - Phone:859-644-2584
Mailing Address - Fax:
Practice Address - Street 1:316B STEAM SHOVEL ROAD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380
Practice Address - Country:US
Practice Address - Phone:859-644-2584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health