Provider Demographics
NPI:1235580820
Name:EVERGREEN SUPPORTED LIVING, LLC
Entity Type:Organization
Organization Name:EVERGREEN SUPPORTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DBA, MSN, CNP
Authorized Official - Phone:614-205-9982
Mailing Address - Street 1:5150 E MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2441
Mailing Address - Country:US
Mailing Address - Phone:614-205-9982
Mailing Address - Fax:
Practice Address - Street 1:5150 E MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:OH
Practice Address - Zip Code:43213-2441
Practice Address - Country:US
Practice Address - Phone:614-205-9982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-25
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care