Provider Demographics
NPI:1326445388
Name:EVERGREEN PLACE LLC
Entity Type:Organization
Organization Name:EVERGREEN PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCGARRY
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:218-652-6702
Mailing Address - Street 1:23299 285TH AVE
Mailing Address - Street 2:
Mailing Address - City:AKELEY
Mailing Address - State:MN
Mailing Address - Zip Code:56433-8020
Mailing Address - Country:US
Mailing Address - Phone:218-652-6702
Mailing Address - Fax:218-652-6710
Practice Address - Street 1:23299 285TH AVE
Practice Address - Street 2:
Practice Address - City:AKELEY
Practice Address - State:MN
Practice Address - Zip Code:56433-8020
Practice Address - Country:US
Practice Address - Phone:218-652-6702
Practice Address - Fax:218-652-6710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1075244311ZA0620X
MN1075464-1HCBS385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No385H00000XRespite Care FacilityRespite Care