Provider Demographics
NPI:1366465403
Name:THE EVERGREENS, INC.
Entity Type:Organization
Organization Name:THE EVERGREENS, INC.
Other - Org Name:EVERGREENS SENIOR HEALTHCARE SYSTEM
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:336-292-8620
Mailing Address - Street 1:4007 W WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1904
Mailing Address - Country:US
Mailing Address - Phone:336-292-8620
Mailing Address - Fax:336-854-7122
Practice Address - Street 1:4007 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1904
Practice Address - Country:US
Practice Address - Phone:336-292-8620
Practice Address - Fax:336-854-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0073311ZA0620X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3405016Medicaid
NC40251OtherPARTNERS INS PROVIDER NO
NC00829OtherBCBS OF NC PROVIDER NO
NC3406162Medicaid
NC0308360001Medicare NSC
NC40251OtherPARTNERS INS PROVIDER NO