Provider Demographics
NPI:1164455762
Name:EVERGREEN MEDICAL CENTER HOSPICE, LLC
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL CENTER HOSPICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT - FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROYCE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WINBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-981-0200
Mailing Address - Street 1:106 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401-3313
Mailing Address - Country:US
Mailing Address - Phone:251-578-2939
Mailing Address - Fax:251-578-9398
Practice Address - Street 1:106 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:AL
Practice Address - Zip Code:36401-3313
Practice Address - Country:US
Practice Address - Phone:251-578-2939
Practice Address - Fax:251-578-9398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11635251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-1631Medicare ID - Type Unspecified