Provider Demographics
NPI:1427178540
Name:EVERGREEN LIVING HOME INC.
Entity Type:Organization
Organization Name:EVERGREEN LIVING HOME INC.
Other - Org Name:EVERGREEN LIVING HOME #11
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:SONG
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-779-5588
Mailing Address - Street 1:PO BOX 2077
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-2077
Mailing Address - Country:US
Mailing Address - Phone:828-779-5588
Mailing Address - Fax:
Practice Address - Street 1:351 FAMILY RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:NC
Practice Address - Zip Code:28748
Practice Address - Country:US
Practice Address - Phone:828-779-5588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-011-196311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805221Medicaid